Aims. To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality. Methods. We retrieved information from the Swedish Fracture Register (SFR) on all patients with acetabular fractures, of the native hip joint in the adult skeleton, sustained between 2014 and 2020. Study variables included patient age, sex, injury date, injury mechanism, fracture classification, treatment, and mortality. Results. In total, 2,132 patients with acetabular fractures from the SFR were included in the study. The majority of the patients were male (62%) and aged over 70 years old (62%). For patients aged > 70 years, the 30-day mortality was 8% and one-year mortality 24%. For patients aged ≤ 70 years, the 30-day mortality was 0.2% and one-year mortality 2%. Low-energy injuries (63%) and anterior wall fractures (20%) were most common. Treatment was most often non-surgical (75%). Conclusion. The majority of patients who sustain an acetabular fracture are elderly (> 70 years), of male sex, and the fracture most commonly occurs after a simple, low-energy fall. Non-surgical treatment is chosen in the majority of acetabular fracture patients. The one-year mortality for elderly patients with acetabular fracture is similar to the mortality after hip fracture, and a similar multidisciplinary approach to care for these patients should be considered. Cite this article: Bone Jt Open 2023;4(9):652–658

Aims. This study explores the epidemiology of patients with a fracture of the scaphoid presenting to a regional teaching hospital. Patients and Methods. All patients with a confirmed fracture of the scaphoid over a retrospective period between January 2010 and May 2013 were included. Their demographics, deprivation status and when the fracture occurred was noted and assessed. There were 415 fractures in 365 males and 50 females. Results. The incidence of fracture of the scaphoid was 12.4 in 100 000 each year in the general population. The mean age of the patients was 22 years (nine to 35); the highest incidence was in males aged between 15 and 19 years. We calculate the annual incidence in the United Kingdom to be 7265 each year. Patients with the lowest socioeconomic status had an incidence of 18.57 in 100 000 whereas the least deprived patients had an incidence of 9.98 (p < 0.001). There was evidence of a seasonal trend (p = 0.022) with the highest monthly rate found in June (16.96 in 100 000 each year) and the lowest was in December (7.61 in 100 000 each year). There were significantly fewer presentations of fracture at the weekend (p <  0.001), and the highest incidence was on Mondays. Most fractures occurred at the waist (64%) and tubercle (18.1%). Take home message: In this large-scale epidemiological study, we confirmed that young men are most at risk of sustaining a fracture of the scaphoid, and report new factors in relation to social deprivation and seasonality that influence scaphoid fractures. Cite this article: Bone Joint J 2016;98-B:654–9

Aims. This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries. Patients and Methods. In England, the Hospital Episode Statistics (HES) data are recorded annually. Between 2000/01 and 2016/17, the number of adults admitted to an English NHS hospital with a calcaneal fracture and whether they underwent surgical treatment was determined. Results. During this 17-year period, 62 858 patients were admitted to hospital with a calcaneal fracture. The male-to-female ratio was 2.66:1. The mean annual incidence was 10.5/100 000 for men and 3.8/100 000 for women. The results of the UK HeFT were published in July 2014. The percentage of patients admitted with a calcaneal fracture undergoing internal fixation was 7.31% (3792/51 859) before and 7.38% (534/7229) after its publication. This difference was not statistically significant (p = 0.94). Since 2015, there has been a significant increase in the percentage of calcaneal fractures treated by closed reduction and internal fixation, as opposed to open reduction and internal fixation, from 7.7% (292/3792) to 13.29% (71/534) (p < 0.001). Conclusion. This study documents the epidemiology and trends in surgical treatment of calcaneal fractures in England. We established that surgeons did not change their practice in terms of offering surgery to these patients in response to the results of the UK HeFT. There has been a significant (p < 0.001) increase in the number of calcaneal fractures being treated surgically using less invasive procedures

Total knee arthroplasty (TKA) is a cost effective and extremely successful operation. As longevity increases, the demand for primary TKA will continue to rise. The success and survivorship of TKAs are dependent on the demographics of the patient, surgical technique and implant-related factors. . Currently the risk of failure of a TKA requiring revision surgery ten years post-operatively is 5%. . The most common indications for revision include aseptic loosening (29.8%), infection (14.8%), and pain (9.5%). Revision surgery poses considerable clinical burdens on patients and financial burdens on healthcare systems. . We present a current concepts review on the epidemiology of failed TKAs using data from worldwide National Joint Registries. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):105–12

Aims

This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?

Aims

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?

Aims

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are recognised and proven interventions for patients with advanced arthritis. Studies to date have demonstrated a steady increase in the requirement for primary and revision procedures. Projected estimates made for the United States show that by 2030 the demand for primary TKA will grow by 673% and for revision TKA by 601% from the level in 2005. For THA the projected estimates are 174% and 137% for primary and revision surgery, respectively. The purpose of this study was to see if those predictions were similar for England and Wales using data from the National Joint Registry and the Office of National Statistics.

Analysis of data for England and Wales suggest that by 2030, the volume of primary and revision TKAs will have increased by 117% and 332%, respectively between 2012 and 2030. The data for the United States translates to a 306% cumulative rate of increase between 2012 and 2030 for revision surgery, which is similar to our predictions for England and Wales.

The predictions from the United States for primary TKA were similar to our upper limit projections. For THA, we predicted an increase of 134% and 31% for primary and revision hip surgery, respectively.

Our model has limitations, however, it highlights the economic burden of arthroplasty in the future in England and Wales as a real and unaddressed problem. This will have significant implications for the provision of health care and the management of orthopaedic services in the future.

Cite this article: Bone Joint J 2015;97-B:1076–1081.

Aims. The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population. Methods. This is a multicentre retrospective cohort study including adult patients presenting to hospital with a new PPF between 1 January 2018 and 31 December 2018. Data collected included: patient characteristics, comorbidities, anticoagulant use, social circumstances, level of mobility, fracture characteristics, Unified Classification System (UCS) type, and details of the original implant. Descriptive analysis by fracture location was performed, and predictors of PPF type were assessed using mixed-effects logistic regression models. Results. In total, 720 femoral PPFs from 27 NHS sites were included. PPF patients were typically elderly (mean 79.9 years (SD 10.6)), female (n = 455; 63.2%), had at least one comorbidity (n = 670; 93.1%), and were reliant on walking aids or bed-/chair-bound prior to admission (n = 419; 61.7%). The study population included 539 (74.9%) hip PPFs, 151 (21.0%) knee PPFs, and 30 (4.2%) dividing type PPFs. For hip (n = 407; 75.5%) and knee (n = 88; 58.3%) arthroplasty UCS B type fractures were most common. Overall, 556 (86.2%) were treated in the presenting hospital and 89 (13.8%) required transfer for treatment. Female sex was the only significant predictor of fracture type (A/B1/C type versus B2/B3) for femoral hip PPFs (odds ratio 0.61 (95% confidence interval 0.41 to 0.91); p = 0.014). Sex, residence type, primary versus revision implant PPF, implant fixation, and time between arthroplasty and PPF were not found to predict fracture type for hip PPFs. Conclusion. This multicentre analysis describes patient and injury factors for patients presenting with femoral PPFs to centres across the UK. These patients are generally elderly and frail, comparable to those sustaining a hip fracture. These data can be useful in planning future services and clinical trials. Cite this article: Bone Joint J 2022;104-B(8):987–996

Aim. Sepsis is a life-threatening complication of periprosthetic joint infections (PJI) that requires early and effective therapy. This study aims to investigate the epidemiology, associated risk factors, and outcome of sepsis in the context of periprosthetic joint infections (PJI). Method. This single-center retrospective cohort study included patients treated for PJI from 2017 to 2020. Patients were classified based on the criteria of the European Bone and Joint Infection Society. The presence of sepsis was determined using the SOFA score and SIRS criteria. The cohort with PJI and sepsis (sepsis) was compared to patients with PJI without sepsis (non-sepsis). Risk factors considered were patient characteristics, affected joints, surgical therapy, microbiological findings, preexisting medical conditions, clinical symptoms, and symptom duration. Outcome parameters were mortality, length of hospital stay, and length of stay in the intensive care unit. Results. A total of 109 patients with PJI were identified, of whom 45 patients (41.3%) met the criteria for sepsis. Patients with sepsis had more severe preexisting diseases compared with the non-sepsis cohort (Charlson Comorbidity Index 3.8 vs. 2.8; p≤0.001). An increased odds ratio (OR) for a septic course was found for the comorbidities pneumonia (8.2; p=0.001), myocardial infarction (2.0; p=0.02), atrial fibrillation (3.3; p=0.01), diabetes mellitus (1.2; p=0.04), endocarditis (5.5; p=0.01), and renal disease (2.0; p≤0.001). Infection with Staphylococcus aureus (sepsis 20 vs. non-sepsis 10; p=0.002), Streptococcus dysgalactiae (sepsis 7 vs. non-sepsis 2; p=0.002) and Candida albicans (sepsis 5 vs. non-sepsis 0; p=0.01) were more prevalent in patients with sepsis. In the sepsis cohort, further infectious foci were present in addition to PJI in 57.8% of patients, compared to 18.8% in the non-sepsis cohort. The presence of sepsis was associated with a longer hospital stay (sepsis 68 days vs. non-sepsis 38 days; p=0.001) and longer intensive care unit stay (sepsis 12 days vs. non-sepsis 2 days; p=0.001). In-hospital mortality was ten times higher in the sepsis cohort compared to non-septic patients (sepsis 11/42 vs. non-sepsis 2/64; OR 10.3; p=0.01). Conclusions. In a relevant proportion of patients, PJI can lead to a septic course of disease associated with increased mortality. Particularly in patients with preexisting diseases, increased attention is required, and comprehensive screening for other foci of infection seems mandatory. In addition to highly virulent pathogens such as staphylococci and streptococci, fungal infections should be considered as causative pathogens in septic patients with PJI

Introduction. Over the past 30 years multiple wars and embargos have reduced healthcare resources, infrastructure, and staff in Iraq. Subsequently, there are a lack of physiotherapists to provide rehabilitation after an anterior cruciate ligament reconstruction (ACLR). The implementation of home-based rehabilitation programmes may provide a potential solution to this problem. This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone. Methods. A cohort observational study of patients aged ≥ 16 years with an ACL rupture who underwent an ACLR under a single surgeon. This was performed arthroscopically using a hamstring autograft (2 portal technique). Patients completed a home-based rehabilitation programme of appropriate simplicity for the home setting. The programme consisted of stretching, range of motion and strengthening exercises based on criterion rehabilitation progressions. A full description of the programme is provided at: . https://ngmvcharity.co.uk/. . Demographics, mechanisms of injury, operative findings, and outcome data (Lysholm, Tegner Activity Scale (TAS), and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics. Results. The cohort consisted of 545 patients (547 knees), 99.6% were male with a mean age of 27.8 years (SD 6.18 years). The mean time from diagnosis to surgery was 40.6 months (SD 40.3). Despite data attrition Lysholm scores improved over the 15-month follow-up period, matched data showed the most improvement occurred within the first 2 months post-operatively. A peak score of 90 was observed at nine months. Post-operative TAS results showed an improvement in level of function but did not reach pre-injury levels by the final follow-up. At final follow-up, six (1.1%) patients required an ACLR revision. Conclusion. Patients who completed a home-based rehabilitation programme in Kurdistan had low revision rates and improved Lysholm scores 15 months post-operatively. To optimise resources, further research should investigate the efficacy of home-based rehabilitation for trauma and elective surgery in low- to middle-income countries and the developed world

Most patients treated at our clinical setting present during chronic osteomyelitis stage, which is anecdotally likely to be poly-microbial. Adults with poly-microbial infection have a predilection for gram-negative bacteria and anaerobes, a scenario that hypothetically leads to a higher morbidity of poly-microbial osteomyelitis following trauma. Our study looks into the epidemiology of poly-microbial osteomyelitis treated at our Tumour and Infection unit. Retrospective study of patients treated for osteomyelitis from 2016 to 2020. Records of eligible patients were retrieved for examination. Demographics such as age, sex and race were recorded. Clinical presentation, organisms cultured, including their anti-microbial sensitivities were documented. There were 63 participants in the study. 31 (49.21%) had mono-microbial osteomyelitis with 32 (50.79%) having poly-microbial osteomyelitis. Majority of the poly-microbial patients presented with a sinus (68.75%) mostly located in the tibia (50%). Multiple mixed pathogens (both gam-positive and gram-negative) were cultured in our patients and this comprised 71.21% of the total bacteria cultured. Staphylococcus Aureus was the commonest bacteria (30%) isolated, followed by Enterococcus faecalis (12%). The commonest gram-negative bacteriae cultured was Enterococcus cloacae (10%) followed by Acinetobacter baumannii (7%). Most enterobacteriacae species were sensitive to Ertapenem and Ceftazidime. A slightly higher incidence of poly-microbial osteomyelitis was found in our study than that reported in literature. Furthermore, our study demonstrated a wide variety of organisms found in poly-microbial osteomyelitis, with a large contribution made by gram-negative anaerobic rod-shaped bacteria

Limb reconstruction requires high levels of patient compliance and impacts heavily on social circumstances. The epidemiology and socioeconomic description of trauma patients has been well documented, however no study has assessed the epidemiology of limb reconstruction patients. The aim of this project is to describe patients attending Limb Reconstruction Services (LRS) in order to highlight and address the social implications of their care. All LRS cases under a single surgeon in a district general hospital were included from 2010 – 2016. Demographics, ASA grade, smoking status, mental health status and employment status were collated. Postcode was converted into an Index of Multiple Deprivation score using GeoConvert® software. Patient socioeconomic status was then ranked into national deprivation score quintiles (quintile 1 is most affluent, quintile 5 is most deprived). Deprivation scores were adjusted by census data and analysed with Student's T-test. The distance from the patient's residence to the hospital was generated through AA route planner®. Patient attendance at clinic and elective or emergency admissions was also assessed. Patient outcomes were not part of this research. There were 53 patients, of which 66% (n=35) were male, with a mean age of 45 years (range 21–89 years). Most patients were smokers (55%, n=29), 83% (n=42) were ASA 1 or 2 (there were no ASA 4 patients). The majority of indications were for acute trauma (49%), chronic complications of trauma (32%), congenital deformity (15%) and salvage fusion (4%). Mental health issues affected 23% (n=12) of cases and 57% of working-aged patients were unemployed. Mental health patients had a higher rate of trauma as an indication than the rest of the cohort (93% vs. 76%). Deprivation quintiles identified that LRS patients were more deprived (63% in quintiles 4 and 5 vs. 12% of 1 and 2), but this failed to reach statistical significance (p=0.9359). The mean distance from residence to hospital was 12 miles (range 0.35–105 miles, median 7 miles). The patients derived from a large region made up of 12 local authorities. There was a mean of 17 individual LRS clinic attendances per patient (range: 3–42). Cumulative distance travelled for each patient during LRS treatment was a mean of 495 miles (range 28 – 2008 miles). The total distance travelled for all 53 patients was over 26,000 miles. The results largely mirror the findings of trauma demographic and socioeconomic epidemiology, due to the majority of LRS indications being post-traumatic in this series. The high rates of unemployment and mental health problems may be a risk factor for requiring LRS management, or may be a product of the treatment. Clinicians may want to consider a social care strategy alongside their surgical strategy and fully utilise their broader MDT to address the social inequalities in these patients. This strategy should include a mental health assessment, smoking cessation therapy, sign-posted support for employment circumstances and a plan for travel to the hospital. The utilisation and cost of ambulance services was not possible with this methodology. Further work should prospectively assess the changes in housing circumstances, community healthcare needs and whether there was a return to employment and independent ambulation at the end of treatment

Trauma patients present with different injuries and some of them require emergency surgical procedures. Orthopaedic department at Steve Biko Academic Hospital (SBAH) have seen an increasing number of patients presenting with serious orthopaedic injuries due to Delivery Motorbike Accidents (DMBA). The aim of the study was to establish the epidemiology and pattern of orthopaedic injuries sustained following Delivery Motorbike Accident. Motor Vehicle Accident (MVA) administration office at SBAH in emergency department was approached for patients registers used between 1 January 2020 and 31 December 2022. There patients were registered as Motor Vehicle Accident (MVA), Motorbike Accident (MBA) and Pedestrian Vehicle Accident (PVA) by the administration office. The details of patients classified as MBA were collected and used to obtain clinical data from medical and radiological records in the form of patient's files and PACS respectively. Approximately 240 patients presented to Emergency department with orthopaedic injuries following a motorbike accident. About 78 files could not be retrieved from the patient's records department. About 74patients had their occupation recorded as unknown or unemployed. Approximately 70 patients had their occupation indicated in the file by the Clinicians or Administration Clerks. About 40 patients had their occupation as delivery man or working for a delivery company. 16 patients did not have images on the PACS system. Most of the patients were males, presented after hours and sustained multiple injuries that were managed surgically. Very few patients had their helmet status indicated in the file. The study suggests that accidents due to delivery motorbikes are prevalent at SBAH and result in orthopaedic injuries. Almost 50% of patients who had their occupation indicated in the file were delivery employees. A follow up prospective study is recommended to ensure complete collection of data from patients at presentation to ED

Aim. Currently, gram-negative bacteria (GNB), including multidrug-resistant (MDR-GNB) pathogens, are gaining importance in the aetiology of prosthetic joint infection (PJI). To characterize the antimicrobial resistance patterns of Gram-negative bacteria (GNB) causing hip prosthetic joint infections in elderly patients treated at a Brazilian tertiary academic hospital. Method. This is a retrospective, cross-sectional study of patients over 60 years of age undergoing hip arthroplasty from 2018 to 2023 at a tertiary academic trauma, which were diagnosed with hip prosthetic joint infection. PJI diagnosed was based on EBJIS criteria, in which intraoperative tissue cultures identified the pathogens. Demographics, reason for arthroplasty, type of implant and susceptibility patterns using disk diffusion method were analysed. Results. Overall, among 17 elderly patients diagnosed with hip infected arthroplasty, 45 bacterial isolated were identified. Debridement, irrigation, antibiotic and implant retention (DAIR) procedures due to uncontrolled infection occurred in 47.0% (n=8/17), and five patients underwent more than two DAIR surgeries. Tissue cultures yielded eleven different bacterial species, with GNB accounted for 64.4% (n=29/45) of pathogens. Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, and Pseudomonas aeruginosa were identified in 34.5% (n=10/29), 17.25% (n=5/29), 13.8% (n=4/29), and 13.8% (n=4/29), respectively. In the resistance profile analysis, E. coli was most sensitive to antibiotics, whereas K. pneumoniae showed resistance rates higher than 70% for cephalosporins, carbapenems, and quinolones. All A. baumannii isolates were resistant to meropenem, and 80% of these isolates were resistant to amikacin. Conclusions. This study emphasizes the role of GNB in the microbiological profile of PJI among elderly patients at a tertiary hospital in a Brazilian centre. The present study portrays a worryingly higher rates of MDR-GNB, mainly to quinolones and cephalosporins resistance which have been the cornerstone of PJI antibiotic treatment. In addition, higher rates carbapenems and aminoglycosides resistance shows a threat to antibiotic treatment of PJI. More global studies need to be carried out to show a likely change in the microbial epidemiology of PJI

Aim. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is commonly associated with serious cases of community-onset skin and musculoskeletal infections (Co-SMSI). Molecular epidemiology analysis of CA-MRSA recovered from skin and soft tissues specimens is lacking in Latin America. This study aimed to identify phenotypic and genotypic features of MRSA isolates recovered from patients presenting Co-SMSI. Methods. Consecutive MRSA isolates recovered from Co-SMSI of patients admitted from March 2022 to January 2023 in a Brazilian teaching hospital were tested for antimicrobial resistance and characterized by their genotypic features. Identification was carried out by automated method and through MALDI-TOF MS. Antimicrobial susceptibility was tested by disk diffusion, broth microdilution and E-test strips for determination of the minimal inhibitory concentration (MIC) according to recommendations from the Brazilian Committee on Antimicrobial Susceptibility Testing (BrCAST) and European Committee on Antimicrobial Susceptibility Testing (EUCAST). Gene mecA characterization and Sccmec typing were performed by multiplex polymerase chain reaction (PCR) assay, and gene lukF detection by single PCR. Patients were prospectively followed up for two months, in order to determine their clinical characteristics and outcomes. Results. Overall, 48 Staphylococcus aureus isolates were obtained from 68 samples recovered from patients with Co-SMSI. Twenty two (42%) were phenotypically characterized as MRSA, although mecA gene was only identified in 20 of those samples. Sccmec was untypable in 12 isolates, Sccmec was type II in 4 isolates and 2 were classified as type IVa. LukF gene was identified in 5 isolates. Antimicrobial resistance profile showed that all isolates were susceptible to linezolid and vancomycin with MIC = 1 and MIC = 2 in 66,7% and 33.3%, respectively. Susceptibility to quinolones was worryingly low and none of the isolates were sensitive to usual doses of ciprofloxacin and levofloxacin, and showed increased rates of resistance to increased exposure to these drugs, as well. Isolates were both susceptible to gentamicin and tetracycline in 85% and resistance to also Sulfamethoxazole/Trimethoprim occurred in only 2 isolates. Mortality rate evaluated within 1 month of the initial evaluation was 10% among MRSA isolates. Conclusions. Our results showed that CA-MRSA isolates causing Co-SMSI demonstrated an alarming pattern of multidrug resistance, including to β-lactam and quinolones, which have been commonly prescribed as empirical therapy for patients with skin, soft tissue and musculoskeletal infections

Introduction. The epidemiology of re-revision total hip arthroplasty (THA) is not well understood. The purpose of this study is to investigate the epidemiology of re-revision THA, and identify risk factors that are associated with failure of re-revision THA. Methods. A retrospective analysis was performed on 288 patients who underwent revision THA at a single institution between 1/2012 and 12/2013. Patients who underwent revision hip arthroplasty two or more times were included. Patients were excluded if their indication for their first revision was due to periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected through the electronic medical record. Re-revision failure was defined as the need for any additional return to the operating room, regardless of indication. A logistic regression analysis was performed to assess for significant predictors of re-revision failure. Results. A total of 51 re-revision patients were included in this study. Mean age at re-revision was 59.6 (±14.2 years). There were 32 (67%) females. Mean BMI was 28.8 (±5.4). Median ASA level was 2 (23; 55%). The median number of revisions was 3 (range 2–11). The most common indication for re-revision was acetabular component loosening (15; 29%), followed by PJI (13; 25%) and instability (9; 18%). Among re-revision patients, the most common indication of the first revision was acetabular component loosening (11; 27%), followed by polyethylene wear (8; 19%) and instability (8; 19%) (Figure 1). There was a significantly increased risk of re-revision failure if the re-revision procedure involved exchanging only the head and polyethylene liner (RR=1.792; p=0.017), if instability was the indication for the first revision (RR=3.000; p<0.001), as well as if instability was the indication for the re-revision (RR=1.867; p=0.038). If only the femoral component was exchanged during the re-revision, there was a decreased risk of failure (RR=0.268, p=0.046). 1-year re-revision survival was 54% (23/43). Discussion. Acetabular component loosening and PJI were the most common indications for re-revision. There was an increased risk of re-revision failure if instability was a cause for reoperation at any point during the revision history, or if only an isolated head and polyethylene liner exchange was indicated during the re-revision procedure. There was a decreased risk of re-revision failure if only an isolated femoral stem revision was performed. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction There are no reports on the epidemiology of revision hip arthroplasty in Australia. The aim of this study was to characterise the epidemiology of revision hip arthroplasty in relation to primary hip replacements in Australia. Methods This study covered the seven year period 1993/1994 to 1999/2000. Data on all primary hip replacements and revisions done were obtained from the Australian Institute of Health and Welfare using the ICD-9 (81.53) and ICD-10 (Block No. 1492) cartegorisation. The data was stratified by age (five year age groups), sex, year and state or territory. Log linear modelling was used to examine the rate of revision procedures out of the total number of procedures (primary and revision). The effects of gender, age and year were examined in a series of hierarchical log-rate models (Poisson Loglinear Regression). Results For the period of the study there were 18,027 revision cases and 122,595 cases of primary hip replacement, representing a revision rate of 14%. The rate of increase of primary hip replacements was significantly higher than the rate of increase of revisions (t= −12.1, p< 0.0005). The number of primary hip replacements performed nationally increased by 810 (95% confidence intervals 658,964) a year. The number of revisions increased by only 62 (95% confidence intervals 21,104) a year. The proportion of revisions decreased by 0.3% per year as determined by regression analysis. The hierarchical log-rate models indicate significant interactions between age and gender and beween age and year. Conclusions The number of primary and revision hip replacements has been increasing with time. The rate of increase of revision hip replacements has been lower. The proportion of hip replacements that are revisions has been gradually dropping, probably due to a greater increase in the number of primary hip replacements

To illustrate the incidence and epidemiology of fractures due to football. All inpatient and outpatient fractures from a prospectively collected database for a defined population in 2000 were retrospectively analysed. There were 396 football fractures, 96% male. Football caused 39% of the 1022 sports fractures in 2000. This represented 5% of the 8151 fractures in total. The incidence was 61/105. 115/105 in males and 5 /105 in females. The average age was 22.9 years; 22.8 in males and 26.6 in females. 77% of fractures were treated as outpatients. The top five fractures representing 84% of the injuries were Radius+Ulna 30%, Phalanx 19%, Tibial+Fibula 18%, Metacarpal 11% and Clavicle 5%. 71% were upper-limb fractures. The busiest two months were October and May 17% and 14% respectively. The quietest two months were February and December at 5%. Although the epidemiology of football injuries will vary amongst different populations, these results can be generalized to similar population bases. Results will be valuable to medical professionals supporting football teams, enabling them to focus their attention on treating the most common injuries, the majority being treated as outpatients. Football is the most common cause of fractures in sport. As participation increases, the incidence of fractures is likely to reflect this. Upper limb fractures account for over 2/3 rd of fractures with radius+ulna fractures accounting for up to a 1/3rd of fractures; the majority can be treated as an outpatient. Therefore medical teams should be familiar with standard treatment regimes, possible impact on players’ futures and time out of sport

Open fractures are uncommon in the UK sporting population, however because of their morbidity then are a significant patient group. Currently there is very little in the literature describing the epidemiology of open fracture in sport. We describe the epidemiology of sport related open fractures from one centre's adult patient population. Retrospective analysis of a prospectively collected database recording all sport related open fracture s over a 15 year period in a standard population. Over the 15 year period, there were 85 fractures in 84 patients. The mean age was 29.2 years (range 15–67). 70 (83%) were male and fourteen female (17%). The six most common sports were football (n=19, 22%), rugby (n=9, 11%), cycling (n=8, 9%), hockey (n=8, 9%); horse riding (n=6, 7%) and skiing (n=6, 7%). The top five anatomical locations were fingers phalanges, 35%; tibia-fibula 23%; foreman 14%; ankle 11% and metacarpals 5%. The mean injury severity score was 7.02. Forty five patients were grade 1; 28 patients were grade 2; 8 patients were grade 3a; and 4 were grade 3b according to the Gustilo-Anderson classification system. Seven patients (8%) required plastic surgical intervention for the treatment of these fractures. The types of flaps used were split skin graft (n=4), fasciocutaneous flaps (n=2); and adipofascial flap (n=1). We looked at the epidemiology open fractures secondary to sport in one centre over a 15 year period. Football was the most common sport (22%) and within football, the most common site was the tibia and fibula. In contrast, within the cohort a whole the majority of fractures were upper limb, with the hand being the most common site. Whilst not common in sport, when they are sustained they are frequently occur on muddy sport fields or forest tracks and must be treated appropriately. A good understanding of the range and variety of injuries commonly sustained in different sports is important for clinicians and sports therapists

Aims. The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality. Methods. A multicentre, cross-sectional retrospective study of MSFs at six centres in the UK. We collected and analyzed healthcare records, operative notes, and radiographs of adults presenting within ten days of a MSF affecting the second to fifth metacarpal between 1 August 2016 and 31 July 2017. Total emergency department (ED) attendances were used to estimate prevalence. Results. A total of 793 patients (75% male, 25% female) with 897 MSFs were included, comprising 0.1% of 837,212 ED attendances. The annual incidence of MSF was 40 per 100,000. The median age was 27 years (IQR 21 to 41); the highest incidence was in men aged 16 to 24 years. Transverse fractures were the most common. Over 80% of all fractures were treated non-surgically, with variation across centres. Overall, 12 types of non-surgical and six types of surgical treatment were used. Fracture pattern, complexity, displacement, and age determined choice of treatment. Patients who were treated surgically required more radiographs and longer radiological and outpatient follow-up, and were more likely to be referred for therapy. Complications occurred in 5% of patients (39/793). Most patients attended planned follow-up, with 20% (160/783) failing to attend at least one or more clinic appointments. Conclusion. MSFs are common hand injuries among young, working (economically active) men, but there is considerable heterogeneity in treatment, rehabilitation, and resource use. They are a burden on healthcare resources and society, thus further research is needed to optimize treatment. Cite this article: Bone Jt Open 2024;5(8):652–661

Aims. The aim of this study was to identify factors associated with five-year cancer-related mortality in patients with limb and trunk soft-tissue sarcoma (STS) and develop and validate machine learning algorithms in order to predict five-year cancer-related mortality in these patients. Methods. Demographic, clinicopathological, and treatment variables of limb and trunk STS patients in the Surveillance, Epidemiology, and End Results Program (SEER) database from 2004 to 2017 were analyzed. Multivariable logistic regression was used to determine factors significantly associated with five-year cancer-related mortality. Various machine learning models were developed and compared using area under the curve (AUC), calibration, and decision curve analysis. The model that performed best on the SEER testing data was further assessed to determine the variables most important in its predictive capacity. This model was externally validated using our institutional dataset. Results. A total of 13,646 patients with STS from the SEER database were included, of whom 35.9% experienced five-year cancer-related mortality. The random forest model performed the best overall and identified tumour size as the most important variable when predicting mortality in patients with STS, followed by M stage, histological subtype, age, and surgical excision. Each variable was significant in logistic regression. External validation yielded an AUC of 0.752. Conclusion. This study identified clinically important variables associated with five-year cancer-related mortality in patients with limb and trunk STS, and developed a predictive model that demonstrated good accuracy and predictability. Orthopaedic oncologists may use these findings to further risk-stratify their patients and recommend an optimal course of treatment. Cite this article: Bone Joint J 2023;105-B(6):702–710

The epidemiology of adult fractures is changing rapidly. The longevity of the population continues to extend with increasing incidence of fragility fractures. The aim of this study was to map the epidemiology of fractures in patients 90 years and older. A retrospective review of all orthopaedic trauma patients over the age of 89 years attending Edinburgh Royal Infirmary in 2000 was performed. All inpatients and outpatients were included. These patients were identified using a prospectively complied database held by the senior author. Patient notes were used to confirm place of residence, mobility, co-morbidity, management, length of admission and place of discharge. 236 fractures (4% of all fractures) were identified. There were 209 (89%) female patients. All were secondary to low energy trauma. More than 50% of the patients were admitted from home and mobilised independently or with a stick. 124 (53%) patients had nil or one co-morbidity, the commonest being dementia and hypertension. Of the 133 neck of femur (NOF) fractures 11 (8%) died as inpatients, and of the 66 patients residing independently in their own home only 5 (8%) returned with the other 61 needing step-up care. The average length of stay in hospital for NOF fractures was 13 days. The majority of patients are female and reside at home, being independently mobile and have limited co-morbidity. The length of stay is relatively long and few patients’ return directly home following a NOF fracture. This, with the ever-growing super-elderly population, will have substantial financial implications in the future

Aims. Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. Methods. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Results. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). Conclusion. The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were treated nonoperatively, locked anterior-plate fixation remains the predominant method of fixation for fractures of the distal radius; this is despite questions and continued debate about the best method of surgical fixation for these injuries. Cite this article: Bone Jt Open 2022;3(8):623–627

Aims. The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis. Methods. Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed. Results. A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001). Conclusion. This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483

Aims. Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK. Methods. Any patient admitted to hospital with an open fracture between 1 June 2021 and 30 September 2021 was included, excluding phalanges and isolated hand injuries. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture. Demographic details, injury, fracture classification, and patient dispersal were detailed. Results. In total, 1,175 patients (median age 47 years (interquartile range (IQR) 29 to 65), 61.0% male (n = 717)) were admitted across 51 sites. A total of 546 patients (47.1%) were employed, 5.4% (n = 63) were diabetic, and 28.8% (n = 335) were smokers. In total, 29.0% of patients (n = 341) had more than one injury and 4.8% (n = 56) had two or more open fractures, while 51.3% of fractures (n = 637) occurred in the lower leg. Fractures sustained in vehicle incidents and collisions are common (38.8%; n = 455) and typically seen in younger patients. A simple fall (35.0%; n = 410) is common in older people. Overall, 69.8% (n = 786) of patients were admitted directly to an orthoplastic centre, 23.0% (n = 259) were transferred to an orthoplastic centre after initial management elsewhere, and 7.2% were managed outwith specialist units (n = 81). Conclusion. This study describes the epidemiology of open fractures in the UK. For a decade, orthopaedic surgeons have been practicing in a guideline-driven, network system without understanding the patient features, injury characteristics, or dispersal processes of the wider population. This work will inform care pathways as the UK looks to the future of trauma networks and guidelines, and how to optimize care for patients with open fractures. Cite this article: Bone Jt Open 2022;3(10):746–752

The aims were: (1) assess the influence of COVID-19 on mortality in hip fracture; (2) identify predictors of COVID-19 status, and (3) investigate whether social lockdown influenced the epidemiology of hip fracture. A multicentre retrospective study was conducted of all patients presenting to six hospitals with hip fracture over a 46-day period (23 days pre-/post-lockdown). Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, ASA grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. Of 317 patients with hip fracture 27 (8.5%) had a positive COVID-19 test; only 7 (26%) had symptoms on admission. COVID-19-positive patients had significantly lower 30-day survival compared to those without COVID-19 (67% versus 92%, p<0.001). COVID-19 was independently associated with increased 30-day mortality adjusting for: (1) age, sex, residence (HR 2.93, p=0.008); (2) Nottingham Hip Fracture Score (HR 3.52, p=0.001), and (3) ASA (HR 3.45, p=0.004). Platelet count predicted subsequent COVID-19 status; a value <217 ×109/L was 68% specific and sensitive (95% CI 58 to 77, p=0.002). A similar number of patients presented with hip fracture pre-lockdown (n=160) and post-lockdown (n=157); there was no significant difference in demographics, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. COVID-19 was independently associated with an increased 30-day mortality in hip fracture. Most patients with COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have urgent implications for the delivery of hip fracture services

Femur shaft fractures (FSF) are markers of high energy transfer after injury. The comprehensive, population based epidemiology of FSF is unknown. The purpose of this prospective study was to describe the epidemiology of FSF with special focus on patient physiology and timing of surgery. A 12-month prospective population-based study was performed on consecutive FSF in a 600,000 population area including all ages and pre-hospital deaths. Patient demographics, mechanism, injury severity score (ISS), shock parameters (SBP, BD and Lactate), transfusion requirement, fracture type (AO), co-morbidities, performed procedure and outcomes were recorded. Patients were categorized: Stable, borderline, unstable and in extremis. A total of 125 patients (20.8/100,000/year) with 134 femur fractures. (62% male, age 37±28 years, ISS 20±19, 51% multiple injuries) were identified in two hospitals. 69 patients (55%) sustained a high energy injury (MVA, MBA, train related, high fall) with 16 (23%) of these being polytrauma patients (ISS 28±12, SBP 98±39, BD 6.5±5.8, Lactate 4±2), 15 (94%) required massive transfusion (12±12 URBC, 8±5 FFP, 1±0.4 PLT, 13±8 Cryo). Of the 125 patients 69% were stable (14.5/100,000/year), 9% borderline (1.8/100,000/year), 4% unstable (0.8/100,000/year) patients and 2% (0.3/100,000/year) were in extremis. 2 borderline, 1 unstable and 2 extremis patients died of severe CHI. One patient in extremis died due to uncontrollable hemorrhage from a pelvic fracture. 20 patients (16%) (3.3/100,000/year) with FSF were prehospital deaths and died due to the severity of their multiorgan injuries or CHI. The overall LOS was 18±15 days and the ICU LOS was 5±6 days. All high energy patients went to theatre within 6±13 hours. 56 patients (45%) sustained a low energy injury. Of these patients 85% had multiple co-morbidities. 8 patients needed 3±1 transfusions and none of the patients died. Time to surgery was 25±37 hrs and LOS was 15±11 days. There were 29 paediatric FSF, 20 of these were low and 9 high energy injuries. Only 3 patients required surgery. LE-FSF are as frequent as HE-FSF. 73% of the femur fractures are complicated (open, compromised physiology, multiple injured, bilateral, elderly with co-morbidities etc.) requiring major resources and highly specialized care

Aims. Mendelian randomization (MR) is considered to overcome the bias of observational studies, but there is no current meta-analysis of MR studies on rheumatoid arthritis (RA). The purpose of this study was to summarize the relationship between potential pathogenic factors and RA risk based on existing MR studies. Methods. PubMed, Web of Science, and Embase were searched for MR studies on influencing factors in relation to RA up to October 2022. Meta-analyses of MR studies assessing correlations between various potential pathogenic factors and RA were conducted. Random-effect and fixed-effect models were used to synthesize the odds ratios of various pathogenic factors and RA. The quality of the study was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology using Mendelian Randomization (STROBE-MR) guidelines. Results. A total of 517 potentially relevant articles were screened, 35 studies were included in the systematic review, and 19 studies were eligible to be included in the meta-analysis. Pooled estimates of 19 included studies (causality between 15 different risk factors and RA) revealed that obesity, smoking, coffee intake, lower education attainment, and Graves’ disease (GD) were related to the increased risk of RA. In contrast, the causality contribution from serum mineral levels (calcium, iron, copper, zinc, magnesium, selenium), alcohol intake, and chronic periodontitis to RA is not significant. Conclusion. Obesity, smoking, education attainment, and GD have real causal effects on the occurrence and development of RA. These results may provide insights into the genetic susceptibility and potential biological pathways of RA. Cite this article: Bone Joint Res 2023;12(9):601–614

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

Aims

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.

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. Methods. We reviewed 4,739 patients diagnosed with primary bone sarcomas from the Surveillance, Epidemiology and End Results (SEER) registry between 2007 and 2015. We examined the impact of race and insurance status associated with the presence of metastatic disease at diagnosis, treatment outcome, and overall survival (OS). Results. Patients with Medicaid (odds ratio (OR) 1.41; 95% confidence interval (CI) 1.15 to 1.72) and uninsured patients (OR 1.90; 95% CI 1.26 to 2.86) had higher risks of metastatic disease at diagnosis compared to patients with health insurance. Compared to White patients, Black (OR 0.63, 95% CI 0.47 to 0.85) and Asian/Pacific Islander (OR 0.65, 95% CI 0.46 to 0.91) were less likely to undergo surgery. In addition, Black patients were less likely to receive chemotherapy (OR 0.67, 95% CI 0.49 to 0.91) compared to White patients. In patients with chondrosarcoma, those with Medicaid had worse OS compared to patients with insurance (hazard ratio (HR) 1.65, 95% CI 1.06 to 2.56). Conclusion. In patients with a bone sarcoma, the cancer stage at diagnosis varied based on insurance status, and racial disparities were identified in treatment. Further studies are needed to identify modifiable factors which can mitigate socioeconomic and racial disparities found in patients with bone sarcomas. Cite this article: Bone Joint Res 2022;11(5):278–291

Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy seen in clinical practice. Approximately 34% of CTS patients undergo carpal tunnel decompression (CTD) surgery, in the UK. We investigated the change in epidemiology of CTD based on sex, age, socio-economic deprivation and geographical location, in Scotland, over the last 20 years. 76,076 CTD were performed between 1996–2015 (71% female, M:F ratio 1:2.4). The overall incidence rate of CTD was 73/100,000 person years. The mean age was 50–59 years old for both sexes. Socio-economic deprivation was associated with higher incidence rates of CTD (most deprived 89/100,000 person years and least deprived 64/100,000 person years) (p<0.01). NHS health boards with low populations and a more rural location had higher incidence rates; mean 98/100,000 person years (range 4–238/100,000 person years) compared to high population heath boards in urban locations; mean 74/100,000 person years (range 4–149/100,000 person years) (p<0.01). There has been a significant increase in number and overall incidence of CTD, in Scotland, during the study period: in 1996, 1,156 CTD performed (incidence 23/100,000 person years) vs. 2015, 5,292 CTD performed (incidence 87/100,000 person years) (p<0.01). We conclude that middle aged females are still the most common demographic undergoing CTD but the incidence rate is increasing over time. There appears to be an association between CTD and socio-economic deprivation. The incidence of CTD, and change over time, differs between health boards

Aim. The frequency of arthroplasty among older people is increasing. Taking care of Prosthetic Joint infection (PJI) in this specific population is a challenge. The purpose of this multicentric retrospective study was to evaluate the bacterial epidemiology of hip and knee PJI in octogenarians and nonagenarians over ten years. Method. Data were collected using two softwares* in each of the 4 Centers participating. Inclusion criteria:. -. age ≥ 80 years PJI (knee or hip). -. between January 2007 and December 2016. -. microbiological data available (strains isolated from osteo-articular samples). Bacterial identification: biochemical methods, followed by Malditof since 2009. For Staphylococcus aureus, Pseudomonas aeruginosa and Enterobacteriaceae, resistance profiles to antibiotics frequently used in PJI were collected. Antimicrobial susceptibility testing: disk diffusion (recommendations: French Society of Microbiology yearly updated). Results. 413 patients were included: median age was 85 years and sex ratio was 0.6. 137 were knee PJI and 276 hip. 34% of the infections occurred < 1 month after implantation, and 49% > 6 months after implantation. Among all bacterial isolates (N=817), there was 55% of Gram positive cocci and 36% of Gram negative rods. 112 (27%) were polymicrobial infections. There was a majority of gram negative rods (41%) among isolates from polymicrobial infections. Concerning drug resistance, there was a stable proportion of ESBL among Enterobacteria (16%), whereas Methicillin resistance among S. aureus decreased from 43% in 2007 to 12% in 2016. Conclusions. An important proportion of PJI in older patients are polymicrobials, and a lot of them involve gram negative rods, almost as frequently as S. aureus. These infections are difficult to treat, and resistance of gram negative strains is one of the obstacles to overcome among these patients where surgery is not always possible. * Sirweb (I2A) and Glims (MIPS)

Aims. The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip. Methods. This was an anonymized comprehensive cohort study of Perthes’ disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children’s hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. Overall, 371 children (396 hips) were newly affected by Perthes’ disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years. Conclusion. Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510–518

Acute Respiratory Distress Syndrome (ARDS) is a rare but important complication of trauma, with a mortality of around 50%, and considerable morbidity amongst survivors. The treatment options currently available are supportive only. Although trauma is known to be an important risk factor, previous studies have been intensive care-based and the epidemiology of ARDS amongst trauma patients remains unknown. We prospectively studied 7387 consecutive admissions to a single University Hospital, providing all trauma care to a well defined population, over an eight year period. Inclusion criteria were admission following trauma, age over thirteen and residence within the catchment area. Fifty five percent of all patients studied were male, the average age was fifty years and 97% of injuries were due to blunt trauma. Thirty-eight (0.5%) patients developed ARDS following trauma, giving an incidence of 0.8 per 100 000 population per annum. The mortality rate was 26%. The incidence of ARDS after isolated thoracic, head, abdominal or extremity injury was less than one percent. The incidence was significantly higher amongst younger patients with a median age of 29 for those developing the condition. High energy trauma was also associated with an increased incidence, with 84% cases arising following a road traffic accident or a fall from a height. The highest incidence was observed amongst patients with multiple injuries. Patients with injuries to two anatomical regions had a higher incidence (up to 2.9%) than those with isolated injuries, and those with injuries to three anatomical regions had a higher incidence still (up to 8.2%). The combination of abdominal and extremity injury was shown on logistic regression to be especially significant. The epidemiology of ARDS following trauma has not previously been defined. The incidence is highest following high energy trauma, in younger patients and in polytraumatised patients. We have identified risk factors for the development of this rare but serious complication of trauma. Vigilant monitoring of those patients who are at increased risk will allow appropriate supportive measures to be instituted at an early stage

Introduction and Objectives: Currently ACL reconstruction is one of the most frequent procedures in Trauma and Orthopedic Surgery. The aim of our study is to analyze the epidemiology of this lesion in the workplace. Materials and Methods: We retrospectively reviewed 268 cases of ACL reconstruction using autologous semitendinosus and rectus medialis muscles. All these surgeries were performed at Fremap Majadahonda during 2005–2006. We excluded patients with concomitant lesion of the PCL and revision surgeries of ACL plasties. We compared the findings of the preoperative MRI and findings during surgery with respect to existent meniscal and chondral lesions. Results: We found that the median time elapsed between the occurrence of the lesion and surgery was 2.2 months and from the lesion to MRI was 1.7 months. On MRI we found 47% of meniscal lesions and 9.5% of chondral lesions, in comparison with 56% and 13% found during surgery. Discussion and Conclusions: More than half our patients had meniscal lesions associated with their ACL tear. We found more meniscal and chondral lesions during surgery than in the preoperative images. We present a stratified statistical study of the differences seen

Introduction. Revision Total Knee Arthroplasty (TKA) is becoming increasingly prevalent as the number of TKA procedures grow in a younger, higher-demand population. Factors associated with patients requiring multiple revision TKAs are not yet well understood. The purpose of this study is to investigate the epidemiology of re-revision TKA, and identify risk factors that are associated with failure of re-revision TKA. Methods. A retrospective analysis was performed on 358 patients who underwent revision TKA at a single institution between 1/2012 and 12/2013. Patients who underwent revision knee arthroplasty two or more times were included. Patients were excluded if their indication for the first revision was periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected. Re-revision failure was defined as the need for any additional operative intervention. A logistic regression analysis was performed to assess for significant predictors of re-revision failure. Results. A total of 66 re-revision TKA patients were included in this study. Mean age at re-revision was 60 (±11 years). There were 48 (73%) females. Mean BMI was 31.8 (±6.9). Median ASA level was 2 (40/59; 68%). Average follow up was 2.1 (±1.0) years, with 68% (45/66) of patients having greater than 2 year follow up (Table 1). The median number of revisions was 2 (range 2–11). The most common indication for re-revision was arthrofibrosis (15; 23%), followed by PJI (14; 21%) and aseptic component loosening (13; 20%). Among re-revision patients, the most common indication of the first revision was aseptic component loosening (17; 30%), followed by arthrofibrosis (16; 28%) and instability (9; 16%) (Table 2). Among the top four indications for re-revision, both the re-revision and initial revision indication were the same. Additionally, 42% of patients possessed the same indication for re-revision as the initial revision. The proportion of patients that had a lateral release performed in either the index procedure or initial revision was higher in re-revisions performed for patellar maltracking (p=0.013). There was a significantly increased risk of re-revision failure if the patient had a higher BMI (OR=1.22; p=0.006). Re-revision survival at 30 days was 92% (60/65), at 1 year was 81% (52/64), and at 2 years 73% (33/45). The indication history of re-revision failure is shown on Table 3. Discussion. Arthrofibrosis and PJI were the most common indications for re-revision. There was an increased risk of re-revision failure in patients with a higher BMI. It was common to have a re-revision TKA for the same indication as the initial revision. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Knee arthroscopy with debridement is commonly performed to treat osteoarthritis and degenerative meniscal tears in older adults; however robust evidence does not support sustained benefit from this procedure. Current Canadian guidelines advise against its use as first line treatment. Characterizing the use of this low value procedure will facilitate efforts to maximize quality of care, minimize harm and decrease healthcare costs. We sought to understand:

Data were derived from National Ambulatory Care Reporting System (NACRS), the Discharge Abstract Database (DAD) and the National Physician Database for years 2011-12 to 2019-20. The study included all elective knee arthroscopies (CCI codes 1.VG.80.DA,1.VG.80.FY and 1.VG.87.DA) performed in day surgery and acute care settings in 9 provinces and 3 territories of Canada. Quebec was not included in the analysis due to different reporting methods. We set a threshold of 60 years of age at which it would be highly unlikely that a patient would undergo arthroscopy to treat anything other than osteoarthritis or degenerative meniscal tear. Trends at national and provincial levels were analyzed using regression. Costs were estimated separately using the 2020 case mix groups (CMG) and comprehensive ambulatory care classification system (CACS) methodologies. Surgeons were classified by decade of graduation from medical school (1989 and prior, 1990-99, 2000-09 and 2010+) and categorized based on the proportion of their patient population who were above (“high proportion inappropriate”) or below (“low proportion inappropriate”) the overall national proportion of ≥ 60 years of age.

The number of knee arthroscopies decreased by 37% (42,785 in 2011-12 to 27,034 in 2019-20) overall and 39% (11,103 in 2011-12 to 6,772 in 2019-20) in those 60 years and older (p 25% of patients 60 years and older. Fifty four percent of surgeons who graduated prior to 1989 were considered high proportion inappropriate, whereas only 30.1% of surgeons who graduated in 2010 or later were considered high proportion inappropriate (p < 0 .0001).

Knee arthroscopy continues to be a common procedure in patients over 60 despite strong evidence for lack of benefit. Lower rates in this population in some provinces are encouraging for potential opportunity for improvement. Efforts at practice change should be targeted at surgeons in practice the longest. Canada spends over $12,000,000 per year on this procedure, decreasing its use could allow these resources to be directed to other areas of orthopaedics that provide higher value care.

The prevalence of Staphylococcus infections do not decrease despite the preventive measures. The methicillin-resistant staphylococcus aureus (MRSA) has become a major nosocomial pathogen in community hospitals and responsible 60% of staph infections. Through this study we try to study the epidemiology of methicillin-resistant Staphylococcus in the bone and joint infections. We report a 2-year study retrospectipevelly about 25 cases of bone and joint infection staphilococcus methicillin-resistant. All patients underwent clinical examination, an inflammatory balance and surgical treatment with sampling and bacteriological study of the removal liquid and regular monitoring in all patients. The mean age was 5 years and a half. The sexe ratio was 1.2. mean follow-up of 3 months. One patient had dificit G6PD. The mostaffected area was the capital in 64% of cases. The most common location was at the knee in 32%. The most frequent diagnosis was arthritis followed by osteomyelitis. The antibiotics of the first intention was based on amoxicillin and clavulanic acid associated with an aminoglycoside. It was effective in 75%, and modified according to the results of susceptibility testing in 10 cases. The average duration of antibiotic therapy in IV was ten days. The duration of treatment by oral route relay varies from 10 to 21 days. The apyrexia on day 1 postoperatively was obtained in 73%. The screening of patients at risk of carrying MRSA and isolation should help keep to a minimum cross transmission of infections and the number of non-colonized patients. Place of antibiotic therapy is preponderant and meets pharmacodynamic and pharmacokinetic criteria that must be followed in order to optimize medical treatment

Purpose. Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in children 9–15 years old. The epidemiology for SCFE in the total population of Sweden has not yet been described. Methods. In a prospective cohort study, we analysed pre- and postoperative radiographs and medical records for all children treated for SCFE in Sweden 2007–2013, and noted demographic data, severity of slip, and surgical procedures performed. Results. We identified 379 Swedish children with primary SCFE 2007–2013; 162 girls, median age 12 (7–15) years, and 217 boys, median age 13 (4–17) years. The cumulative incidence was 45.8/100 000 for girls and 58.2/100 000 for boys. As an initial symptom, 66% of the children had hip/groin pain and 12% knee pain. At first presentation, 7% of the children had bilateral SCFE. Prophylactic fixation was performed in 43% . Of the remaining children, 21% later developed a contralateral slip. Fixation with implants permitting further growth of the femoral neck was used in 90% of the children. Femoral neck osteotomy was performed for 11 hips. Of 34 treating hospitals, only three treated > 3 children with SCFE annually. Conclusions. The cumulative incidence 2007–2013 in the total population in Sweden showed a mild increase for girls. The male-to-female ratio was lower than previously described for Sweden. Prophylactic fixation was performed in 43% of the children. Fixation with an implant that allows further growth was used for 90% of the children. Most hospitals in Sweden treat < 2 children annually

Femoral fractures in children is the commonest cause for hospitalization in our institution. It was decided to investigate the epidemiology of these fractures. All cases of traumatic femoral fractures in patients under the age of 18 were retrospectively analysed, in children hospitalised between 2003 and 2005. Pathologic fractures were excluded. Fractures were divided into 3 groups, proximal fractures, diaphyseal fractures and distal metaphyseal fractures. 845 Fractures were included in the study. 7.5% were proximal fractures, 76.2% were fractures of the diaphysis, and 16.3% were distal metaphyseal fractures. Road accidents were the commonest cause in all 3 groups, accounting for 38% of the fractures. In the proximal fracture group (63 fractures) the sex ratio was equal, the average age was 9 years and the mean hospital stay was 13 days. 52.4% Were surgically treated. Of the diaphyseal fractures (644) the sex ratio was 2 males to 1 female, the average age was 6.2 years, and the average hospital stay was 6 days. Only 7% were treated surgically. Of the distal femoral fractures (138) the sex ratio was 3 males to 1 female. 21% Of these were due to sports injuries, all occurring in children over the age of 12, and nearly all boys. 15.2% were treated surgically. The average age was 11.2 years, and the average hospital stay was 7 days. The authors conclude that diaphyseal fractures were the commonest type, and that each fracture group had its own characteristics. The epidemiological aetiology of diaphyseal fractures in this study differed in some aspects from other reported studies

Introduction: Recent data from the UK suggests that the incidence of osteomyelitis in the paediatric population is declining. However, the incidence in the Scandic countries has risen in the late eighties and nineties. We undertook to examine the epidemiology of osteomyelitis presenting to a paediatric teaching hospital in an Irish urban setting. Patients and Methods: We undertook a retrospective review to identify patients admitted over a twenty-five year period with a diagnosis of osteomyelitis. Patients were identified from hospital records, theatre log-books and a departmental database. Demographic data was collected, as were details of the infected bony structure, treatment required and organism cultured. Results: A total of 291 patients were admitted over a twenty-four year period, from 1977 to 2000. A marked reduction in osteomyelitis was noted over the twenty-four year incidence of the study. In addition, a shift in the causative organism was noted from an incidence of H Influenzae in the 70’s of up to 30%, to less than 5% in the 90’s. The treatment regime changed markedly over the course of the study period, with a significantly reduced duration of hospital stay reflecting the move away from protracted periods of hospitalisation. Conclusion: A marked fall in osteomyelitis has occurred in the paediatric population. This may be due to improved living conditions and the introduction of H Influenzae vaccinations. The duration of hospital stay has declined markedly and the introduction of newer imaging modalities has aided diagnosis, allowing early aggressive intervention. However, as osteomyelitis is becoming increasingly rare, a higher index of suspicion is required, particularly from non-specialists who are more likely to be the first to encounter these patients

Introduction: The skeleton is the most common location for metastases, with life-time prevalences of 15% and 70% during autopsies. The Vienna Bone and Soft Tissue Tumor Registry has been established in 1965 and is collecting data on primary and secondary malignancies of the musculoskeletal apparatus ever since. The objective of this study was to review the epidemiology and survival of patients undergoing spinal stabilization, including an analysis of trends over time. Methods: Data on patients operated on between 1980 and 2007 were available from the Tumor registry. Information on location of metastases, number of metastases within and outside the spine, primary tumor, as well as complications and recurrences after treatment were extracted. Survival after surgery was assessed using the Kaplan-Meier method, adjusting for patient age by Lexis expansion. Furthermore, the dataset was expanded on calendar time to test changes in epidemiology and survival during the observed 28 years. The effect of the abovementioned variables on survival was assessed in a Cox regression model using patient age and calendar time as time frame. Results: Data on 254 patients could be ed. The most common primary diagnoses were hypernephroma (26.4%), breast cancer (19.75), and lung cancer (12.2%), mostly metastasizing to thoracic and lumbosacral spine (40% both). 104 patients (47.9%) had multiple spinal and 41 (16.1%) other osseous non-spinal metastases. 14.6% had complications in the immediate postoperative follow-up, 4.3% suffered from recurrences postoperatively. Average survival after surgery was 0.9 years (95%CI 0.7 to 1.0) with an average patient age of 60.4 years (95%CI 58.8 to 62.0). In the regression model location of metastases (p=0.008), primary malignancy (p< 0.001), and recurrences (p=0.008) were associated with decreases in survival. There was no association between survival time and the decade during which patients were treated (p=0.157). However, there were significantly less complications in patients treated in later decades, demonstrating the patient’s benefit of being referred to a specialized centre (p=0.015). Discussion: For our study, we are able to draw from experience of 28 years with stabilization due to spinal metastases. Analyzing the data from 254 patients we observed that spinal metastases stem from a similar pattern of primary malignancies. The average survival in our cohort was less than a year, with a very narrow confidence interval. While survival was not associated with later periods of follow-up, number of complications was, supporting the recommendation to refer cancer patients to specialized centers with appropriate experience. The external validity of our findings, however, is confined by the source of our patients, which comprises mostly central and eastern European patients, and few cases referred from more remote areas

Aims

The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury.

Introduction. This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation. Patients and Methods. From a prospective database we identified and analysed all patients who had sustained a fracture of the radial head or neck over a one year period. The degree of social deprivation was assessed using the Carstairs and Morris index. The relationship between demographic data, fracture characteristics and deprivation categories was determined using statistical analysis. Results. Two hundred and ninety radial head (n=203) and neck (n=87) fractures were diagnosed with a mean age of 44.3years (13–94). There was no significant difference with regards age or gender predominance when comparing radial head and neck fractures directly. The mean age of males was significantly younger when compared to females for radial head (p<0.001) and neck (p<0.001) fractures, but with no gender predominance seen. Associated injuries (n=25) were related to increasing age (p=0.006), radial head fractures (p=0.003) and increasing fracture complexity according to the Mason classification (p<0.001). Social deprivation was related to the mean age at the time of fracture and the mechanism of injury (p<0.05 for both). Conclusions. Proximal radial fractures are frequently fragility fractures affecting older females and assessment for osteoporosis is recommended. Complex radial head fractures require thorough investigation for the presence of associated injuries

Introduction: We present the world’s largest current series of open distal radial fractures (ODRF), aiming to describe the epidemiology and outcomes of these injuries. Methods: Patients with ODRF treated at the Edinburgh Orthopaedic Trauma unit between 1990 and 2009 were identified from computer records. All patients aged over 13 with juxta-articular and metaphyseal fractures were included – diaphyseal injuries were excluded. The following information was retrieved from notes and radiographs: patient demographics; co-morbidities; mechanism of injury; AO classification; other injuries; time to A& E treatment; time until surgery; antibiotic use; Gustillo and Anderson (GA) grade; surgical treatment; complications; further surgery; functional outcome. Results: 201 patients were included. The average age was 65.5 years, 75% were female. 69% resulted from simple falls, 15% falls from height, 6% sporting injuries and 9% from road traffic accidents. 73 % were GA-1, 26% were GA-2, 1% GA-3. The commonest fracture pattern was AO 23-C2. 41% underwent definitive debridement within 6 hours, 46% in 6 to 24 hours, 13% waited longer. 30% were treated by ORIF, 38% with non-bridging fixator, 29% by bridging fixator and 3% by MUA and plaster. 43% of wounds were closed primarily, 47% were left open, 8% required delayed closure, 2% required skin grafting. Follow-up averaged 16.5 weeks. 14% suffered superficial infections, 1.3% suffered deep infection. Predictors of infection included primary closure and the use of an external fixator. Functional outcome was variable. Discussion: Most open distal radial fractures occur in elderly women after a simple fall. Serious infection rates are low

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted. Demographic data were recorded prospectively for each patient with an acute clavicle fractures including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson system. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. More than half of simple fall fractures affected the lateral clavicle. The incidence of clavicle fractures has risen over a twenty year period, and a greater proportion of older adults are now affected. Overall, type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region

Background: Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries. Purpose: The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future. Study design: Descriptive epidemiological study. Methods: Medical personnel prospectively recorded injuries in professional, premiership rugby union players in England over 4 seasons. Injuries to the foot were identified and the time away from training and playing was reported. Results: A total of 147-foot injuries were sustained resulting in 3,542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p< 0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days. Conclusions: In collision sports, such as rugby, injury is inevitable, but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed significant morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided

We investigated the epidemiology, assessment and outcome of acute atraumatic limp in 243 children under the age of 14 years presenting to a paediatric accident and emergency department (AED) over a period of six months. Data were collected at presentation and medical notes were re-examined after 18 to 21 months. The incidence of limp was 1.8 per thousand. The male:female ratio was 1.7:1 and the median age 4.35 years. Limp was mainly right-sided (54%) and painful (80%); 33.7% of the children had localised pain in the hip. A preceding illness was found in 40%. The main diagnosis was ‘irritable hip’/transient synovitis (39.5%); Perthes’ disease accounted for 2%. Most patients (77%) were managed entirely in the AED. Acute atraumatic limp is a common problem in children presenting to the AED. Most can be safely managed there if guidelines are followed and will have a benign outcome. Further studies are needed to identify the role of preceding illness in the aetiology of acute atraumatic limp

Background. A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. Aims. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. Methods. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted over a 12 month period, beginning July 2007. Demographic data were recorded prospectively for each patient presenting with an acute clavicle fracture including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson Classification system. Results. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. An association between age, mode of injury and fracture type was observed, with younger patients sustaining high energy injury associated with majority of the Type II midshaft fractures; whilst more than fifty-nine percent of Type III lateral one third fractures occur in elderly patients as a result of simple fall. Overall, Type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. Conclusions. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of Type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region

Aim. Bone and joint infections (BJI) are associated with a heavy morbidity and high health costs. Comorbidities, device associated infections and complicated journeys are associated with increased mortality, treatment failures and costs. For this reason, 24 referral centers (RC) have been created in 2009 in order to advise about management of “complex” BJI in weekly multidisciplinary meetings (MM). Since end of 2012, data from these meetings are gathered in a national database. We aimed to describe the data from this French registry of BJI and determine factors associated with the definition of “complex” BJI. Method. Demographic, clinical, microbiologic and therapeutic characteristics of patients are systematically recorded in the database. Data from the first presentation in RC for each adult patients are presented. Complexity of BJI is recorded after each meeting according to 4 criteria (first failure, complex antibiotic therapy, precarious underlying conditions or complex surgical procedure). Part of unavailable data have been completed by pattern extraction from text-encoded commentaries. Factors associated with complexity were determined by multivariate logistic regression. Results. From 2012 to 2016, 17.527 patients were included corresponding to 30.300 presentations in MM. Median age was 64 years (IQR 50–76) with masculine predominance (61.8%). Comorbidity was present in 50.3%, with at least 2 comorbidities in 26%. Prosthetic joint infection represented 41.4% of patients, followed by chronic osteitis with/without foreign material (24%). Definite microbiologic documentation was available in 68.8% of cases, mostly Staphylococcus aureus (43.9%) followed by Coagulase negative Staphylococci (28.6%) and enterobacteriaceae (23.1%), with 27.4% of polybacterial infections. Antibiotic treatment was proposed in 81.6% and surgery in 70% of cases. BJI were defined as complex in 55.4%, mostly because underlying conditions (50%), and in 57.6% with at least 2 complexity criteria. Factors positively associated with definition of complexity in MM were: background: number of comorbidities, immunodeficiency, neoplasia, liver or kidney failure, intra-cardiac device; microbiology: Mycobacteria, Fungus, MRSA, MSSA, MR-CoNS, MDR enterobacteria, non-fermentative BGN, and atypical pathogens (actinomycetes, nocardia, intra-cellular …); infection characteristics: prosthetic joint infection, osteitis, foreign material infection, arthritis and number of infected sites; surgical procedures: surgical flap, 2 stages prosthesis exchange, spacer, arthrodesis, and joint removal. Simple debridement was negatively associated with complex definition. Conclusions. This registry is the first national prospective database about management of BJI in France and provide many information about epidemiology and management of BJI in France, as well as a more precise definition of complexity

Aim. Pubic osteomyelitis (PO) is one of less frequent Bone and Joint Infections forms (BJI). Its management is still poorly codified as far as nosological framework is still unclear in medical literature. We aim to describe PO epidemiology and to look for factors associated with management failure. Method. We performed a retrospective cohort study, carried out in two Reference Centres, including patients with PO in 2010–2016. Treatment failure was defined by: (i) persistence of clinical signs despite treatment; (ii) clinical relapse with same microorganisms; (iii) infection recurrence with one or more different microorganism(s);. (iv) new signs of infection (abscess, sinus tract) in same area, without recourse to get microbiological documentation. Factors associated with management failure were determined by univariate Cox analysis (hazard ratio [HR] and 95% confidence interval calculation). Kaplan-Meier curve were compared between groups by log-rank test. Results. Twenty-five patients were included over thirteen years (median age 67 years; 19 men, median ASA score 3). Six (24 %) had a PO from haematogenous origin. Those were all monomicrobial infection, due to S.aureus, mostly identified in young patients without comorbidities, especially in athletes. No surgery was required if no abcess or bone sequestrum were found. Nineteen patients (76 %) had a post-operative chronic PO (developed from 1 month to 11 years after a pelvic surgery); 15 of them had history of pelvic cancer (60%); 12 received radiotherapy at the site of infection (48 %). Infection was polymicrobial in 68 % of cases, including 32 % of cases with multidrug-resistant pathogens. A clinical success was recorded in only 14 patients (56%). Treatment failure was always noticed in chronic post-operative forms. Potential risk factors associated with failure management were: pelvic cancer history (HR 3.8; p=0,089); pelvic radiotherapy history (HR 2.9; p=0.122); clinical sinus tract (HR 5.1; p=0,011); infection with multidrug-resistant bacteria (HR 2.8; p=0,116), and polymicrobial infection (HR 70.5; p=0,090). Conclusions. Our study highlights predominant chronic complex post-operative forms of PO. They are mostly plurimicrobial, sometimes associated with multi-drug resistance, occurring in fragile patients with pelvic cancer. It frequently leads to complex antibiotherapy, with important risk of relapse. Aggressive surgical procedure with large bone resection is frequently required in patients who underwent pelvic radiotherapy

It is has been suggested that as a result of the skewed age distribution, the incidence of hip fracture will increase disproportionately among Asians. The epidemiology of hip fracture among the Asian and White populations in Leicestershire the five year survival between the two groups was investigated. All patients in Leicestershire with hip fracture between 2001–2 were studied. Demographic data, type of fracture, and treatment was recorded. Ethnic origin was noted as White, Asian, or other. Survival at 5 years was documented as number of days survived. The results were analysed statistically. On thousand one hundred and thirty-four patients were admitted to our unit with hip fracture, 617 intracapsular fractures and 517 extracapsular fractures. Leicestershire Census data in 2002 showed that 85.7% of the population was white, 11.9% Asian and the remaining 2.4% of other ethnic group. The percentage of Asians > 65 years was 8.8% compared to 18.9% of whites. The number of Asian patients < 65 years with a hip fracture was significantly greater than the number of whites < 65 years (p =0.002, Fishers exact test). Five year survival of Asian patients < 65 years with hip fracture was significantly lower than white counterparts in the same age group (p = 0.002). Over the last decade there has been a 30% increase in the Asian population in Leicestershire (9.3% to 11.9%). The proportion of Asians over 65 years doubled over the last decade from 4.3% to 8.8%. The proportion of Whites over 65 years increased from 16.3% to 18.9%. The 5 year survival of Asians with hip fracture under 65 years old is significantly reduced when compared to Whites. This suggests that Asians under the age of 65 years that sustain hip fracture may have other risk factors that may contribute to their earlier demise

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered

Aims. This study aimed to describe the use of revision knee arthroplasty in Australia and examine changes in lifetime risk over a decade. Methods. De-identified individual-level data on all revision knee arthroplasties performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data and life tables were obtained from the Australian Bureau of Statistics. The lifetime risk of revision surgery was calculated for each year using a standardized formula. Separate calculations were undertaken for males and females. Results. In total, 43,188 revision knee arthroplasty procedures were performed in Australia during the study period, with a median age at surgery of 69 years (interquartile range (IQR) 62 to 76). In 2017, revision knee arthroplasty rates were highest for males aged 70 to 79 years (102.9 procedures per 100,000 population). Lifetime risk of revision knee arthroplasty for females increased slightly from 1.61% (95% confidence interval (CI) 1.53% to 1.69%) in 2007 to 2.22% (95% CI 2.13% to 2.31%) in 2017. A similar pattern was evident for males, with a lifetime risk of 1.43% (95% CI 1.36% to 1.51%) in 2007 and 2.02% (95% CI 1.93% to 2.11%) in 2017. A decline in procedures performed for loosening/lysis (from 41% in 2007 to 24% in 2017) and pain (from 14% to 9%) was evident, while infection became an increasingly common indication (from 19% in 2007 to 29% in 2017). Conclusion. Well-validated national registry data can help us understand the epidemiology of revision knee arthroplasty, including changing clinical indications. Despite a small increase over a decade, the lifetime risk of revision knee arthroplasty in Australia is low at one in 45 females and one in 50 males. These methods offer a population-level approach to quantifying revision burden that can be used for ongoing national surveillance and between-country comparisons. Cite this article: Bone Joint J 2022;104-B(5):613–619

Pelvic fractures in children are uncommon. Despite their potentially serious nature, there is little information in the literature regarding their epidemiology. We performed a retrospective review of case notes and radiographs, if available, of all patients admitted with bony pelvic injuries to our unit over a 28 year period (1980-2008). Sixty-four children with pelvic fractures were identified (median age 8 years, 75% male). 58% were pedestrians involved in road traffic accidents (RTA), 19% were caused by a fall from a height and 8% were crush injuries. There was seasonal variability, with a 50% increase in pelvic injuries in Autumn and 33% decrease in Winter - compared to Spring/Summer months (in contrast to the peak in overall fracture incidence in the Summer). Median length of stay was 8 days (range 1-180), 11% requiring direct admission to ITU and 5% to HDU. There is a high incidence of associated major injuries - for Stable fractures 52%, Partially stable fractures 60% and Unstable fractures 100%. Five required surgery to the bony pelvis, and 6 for-non pelvic orthopaedic injury. 3 required operative intervention from other specialities, 1 urological repair, 1 laparotomy and 1 lobectomy. Pelvic fractures in children are potentially serious injuries with a high proportion of major associated injuries. Multiple injuries were sustained in 55% of pedestrian/RTA accidents, 100% of crush injuries and 58% of falls from a height. In this series, 52% of “Stable” pelvic injuries were associated with other major injuries. All paediatric pelvic injuries, even stable pubic rami fractures should be approached with caution, full ATLS assessment and close monitoring

Aims. The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). Methods. This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define ‘at risk’. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE. Conclusion. The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519–528

Introduction. A previous study in South Africa showed the prevalence of HIV related osteo-articular sepsis in children to be around 20% with a high prevalence of Streptococcus pneumoniae (38%) in HIV positive patients. This initial study was conducted at the same time that the polyvalent S pneumoniae vaccine was introduced to the EPI in South Africa (2009). The aim of the current study was to review the epidemiology of osteo-articular infections at two hospitals after the introduction of this vaccine. Methods. A retrospective review of patients presenting to two hospitals, between July 2009 and January 2013, with acute osteo-articular sepsis and pus at arthrotomy. The NHLS laboratory results were reviewed for microscopy, culture and sensitivity as well as white cell count (WCC), C reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Results. A total of 100 cases of acute osteo-articular sepsis were identified during this period. The prevalence of HIV was 15%. The most common bacterial isolate was Staphylococcus aureus (22%). There were no Streptococcus pneumoniae isolates grown in either of the two groups. There was no difference in the WCC, CRP and ESR between the HIV negative and positive groups. Conclusion. We have seen a dramatic shift in the bacteriology in paediatric patients with osteo-articular sepsis since the original study in 2009. The incidence of HIV in our study population has declined. This may be due to the introduction of mother to child transmission programmes and increased use of anti-retrovirals. Staphylococcus aureus is now the most common isolated organism in patients with osteo-articular sepsis, regardless of HIV status. The empiric antibiotic therapy of choice in paediatric patients with osteo-articular sepsis remains Cloxacillin. NO DISCLOSURES

Objective: To ascertain the epidemiology of ankle injuries in elite youth football. Design: Retrospective analysis of prospectively collected injury data from English Football Association Academies. Setting: Forty-one FA Football Academies, between 1998 and 2006. Participants: For the complete seasons studied, a total of 14776 players were registered from U9 to the U16 age category – a mean of 2463 players per year. All ankle injuries of sufficient severity to miss 48 hours or more training were studied – 2563 injuries in total. Main outcome measurements: The incidence and burden of ankle injuries in this population, and factors associated with injury. Results: There was a mean incidence of one ankle injury per player per year, and a mean of 20 training days and 2 matches were missed per ankle injury. Increased injury rates were seen in older players, in competition and later in each half of match time. Peaks in injury were observed early in the season and after the winter break. In competition, more injuries were associated with a contact situation than in training. Eighty-eight injuries (3.4%) required a lay-off of three months or more and in 18 (0.7%) cases, the player failed to return to training. In total, 52290 training days and 5182 match appearances were lost through ankle injury. The majority of injuries were sprains, but more severe injuries occurred accounted for 3.9% of the total. Conclusions: Ankle injuries are common in young football players, and are often severe, with prolonged loss of training time. This has potential far reaching implications, both on and off the field. Further syudy in this area is suggested

Introduction: Spinal fractures are associated with pain, disability, neurological dysfunction and mortality. Osteoporosis and risky leisure time activities are increasing in the population. New treatment options have been introduced. However, only a few international studies have reported its descriptive epidemiology. There are no clear consensuses regarding the choice of operative interventions versus non-operative treatment in patients with thoracolumbar fractures. Treatment is often based on local traditions, skills and experiences. The aim of this nationwide study is to analyse the incidence, the characteristics of the patients, the subsequent development, surgical incidence and mortality rate among hospitalized patients with thoracolumbar fractures in Sweden. Methods: All discharges between 1997 and 2000 with diagnoses of thoracic or lumbar vertebrae fracture according to ICD 10 classification were selected from the National Inpatient Register. Surgery in these patients was categorised by procedure codes indicating spine operations. In order to calculate the risk of patients dying, linkage was performed to the Swedish Death Register using the unique personal identification number. Results: We identified 13, 496 admissions during the study period. This corresponds to an incidence rate of 30 per 100, 000 person-years and the occurrence was stable during 1997 and 2001 for patients younger than 50 years but decreased for patients above 50 years. The incidence of spine surgery among all patients was 1.9 per 100, 000 person-years, ranging from 1.6 per 100, 000 inhabitants per year to 2.6 per 100, 000 in the different region of Sweden. The most common causes of the fracture were falls (53 %) followed by vehicle accidents (37%). Almost two thirds of the patients operated on were men (63 %) and two thirds had lumbar vertebral fractures (66 %). The median age of the patients operated on was 42 years. The median length of stay was eight days. Among those who was operated the 30 days case fatality rate was 0.7 %. Median age for death was 64 years. Operations were less common in women (OR 0.79). The number of patients operated on during the last study year 2001 was significantly increased (OR 1.29). The probability of being operated on was highest in the more urban and densely populated regions of Stockholm and southern Sweden. Discussion: This national study based study showed a stable cumulative incidence of thoracolumbar fractures over the year 1997–2000. However, the two last year of this study an increased incidence of operation was observed. A possible explanation of this finding could be the new percutaneus technique for verterbroplasty. We find it of most importance to further investigate the reasons behind the gender differences in surgical incidence in patients with vertebral fractures

Aim: To determine the epidemiology of total knee replacement in our hospital over two 12 month periods 5 years apart to see if patient BMI and demographics have changed. Methods: Hospital theatre log books were examined to determine all primary total knee replacements carried out in our hospital during May 2000 – April 2001 and May 2005 – April 2006. Patient notes were examined and the following details were recorded: age, sex and BMI. Data was recorded on an excel spreadsheet. Results: There was a significant increase in the number of patients undergoing TKR in the 2005 – 2006 time period despite no change in population served (100 vs 228, p< 0.0001). This is also a higher than expected increase in TKR surgery when compared to the national data from the arthroplasty register. There was no significant change in the age of patients undergoing TKR. There was a significant increase in the average BMI of female patients 30.2+\−5.33 vs 32 +\− 6.98 (p=0.03) but no significant difference in the BMI of males. There was also a significant increase in the number of female patients with morbid obesity (BMI> 40) 3\64 vs 19/153 p=0.047. It would appear that there has been a significant increase in the demand for TKR over a relatively short time period and that there are approximately twice as many women needing TKR than men. Within the females there has been a significant increase in BMI and also a significant increase in those who are morbidly obese undergoing TKR. This data helps predict future demand for both primary and revision arthroplasty services in our hospital

Aim. To describe the epidemiology, clinical features and outcomes of native joint septic arthritis in adults admitted to Middlemore Hospital in Auckland, New Zealand. Method. Single-centre retrospective cohort study from 2009 to 2014. Patients ≥16 years of age were identified using ICD-10AM coding data. Electronic records were reviewed for demographic, clinical, laboratory, treatment and outcome data. Total and hemi-arthroplasty infections were excluded. Results. 543 episodes in 521 patients were included, with 90% fulfilling Modified Newman's criteria. Septic arthritis incidence was 26/100,000 patient years and was unchanged over the study period. Incidence correlated strongly with age (R. 2. =0.79) and socioeconomic deprivation (R. 2. =0.76). Median age was 49 years, and gender 70% male. Ethnicity was Pacific Island in 36% (22.8% of catchment population). The most commonly involved joints were hand interphalangeal (19%), knee (19%), metacarpophalangeal (17%) and glenohumeral (11%). Arthritis was monoarticular in 93%. Underlying conditions included current smoking (42%), osteoarthritis (29%), diabetes (22%) and gout (15%). Rheumatoid and seronegative arthritis were uncommon (each 2%). Skin/soft tissue infection occurred within 3 months prior in 38%. Osteomyelitis occurred in 26%. Sources of infection included haematogenous (42%), traumatic (34%), and iatrogenic (17%). Causative organism(s) were isolated in 80% of episodes, most commonly Staphylococcus aureus (53%, 13% of which were MRSA) then Streptococcus pyogenes (15%). 28% of culture-positive episodes were polymicrobial. Median antibiotic duration was 4 weeks, with 38% having definitive therapy orally. A median of 1 surgical procedure was undertaken during treatment. Mortality at 30 days was 3%, at 90 days 5% and treatment failure (defined as any of: death <90 days; relapse; reinfection; or ongoing joint infection leading to readmission, amputation, arthrodesis or excision arthroplasty) occurred in 17%. Treatment failure was significantly more common in cases involving large joints (23%, (69/302) vs. 11%, (26/241), p=0.0002) and in haematogenous episodes versus traumatic episodes (21% (47/229) vs. 10% (19/168), p=0.0045). Conclusions. This is the largest series of adult native joint septic arthritis currently available. The extremely high observed septic arthritis incidence (26/100,000 person years) may relate to high rates of skin and soft tissue infection in Auckland, particularly among Pacific people. Small joint infection, often excluded from previous studies, is associated with significantly better outcomes than large-joint infection. Mortality is lower in this cohort than previously reported, possibly due to the inclusion of small joint infections and exclusion of prosthetic joint infections. Acknowledgements. No additional funding was received for this work

Alternative bearing surfaces has been introduced to reduce wear debris-induced osteolysis after total hip arthroplasty (THA) and offered favorable results. Large population-based data for total joint surgery permit timely recognition of adverse results and prediction of events in the future. The purpose of this study was to present the epidemiology and national trends of bearing surface usage in primary total hip arthroplasty (THA) in Korea using nationwide database. A total of 30,881 THAs were analyzed using the Korean Health Insurance Review and Assessment Service database for 2007 through 2011. Bearing surfaces were sub-grouped according to device code for national health insurance claims and consisted of ceramic-on-ceramic (CoC), metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and metal-on-metal (MoM). The prevalence of each type of bearing surface was calculated and stratified by age, gender, hospital type, primary payer, and procedure volume of each hospital. The number of primary THAs increased by 25.2% from 5,484 in 2007 to 6,866 in 2011. The average age of the entire study population was 58.1 years, and 53.5% were male [Table 1]. CoC was the most commonly used bearing surface (76.7%), followed by MoP (11.9%), CoP (7.3%), and MoM (4.1%). The distribution of bearing surfaces was identical to that in the general population regardless of age, gender, hospital type, and primary payer [Table 2]. The mean age of patients that received hard-on-hard bearing surfaces (CoC and MoM) was significantly younger than that of patients receiving hard-on-soft bearing surfaces (CoP and MoP) (56.9 years vs. 62.6 years). During the study period, 55.1% of THAs that used a hard-on-hard bearing surface were performed in males, while 53.0% of THAs that used a hard-on-soft bearing surface were performed in females. The order of prevalence of bearing surfaces was identical in low- and medium-volume hospitals (CoC was first, MoP was second, CoP was third, and MoM was fourth). The mean hospital charges did not differ according to the bearing surface used, with the exception of CoP, which was associated with a lower mean hospital charge. There were no changes in the distribution of bearing surfaces in each year between 2007 and 2011. Overall, the percentage of THAs that used CoC bearing surfaces increased substantially from 71.6% in 2007 to 81.4% in 2011, while the percentage that used CoP, MoP, and MoM decreased significantly [Fig. 1]. One of the reasons for the dominant usage of hard-on-hard bearing surfaces may be that the principal diagnosis of primary THAs and the patient age group distribution in Korea differ from those in other countries. The most common indication for primary THA is osteonecrosis of the femoral head in Korea. In contrast, the majority of primary THAs are performed for osteoarthritis in Western countries. The choice of bearing surface may be affected by many factors, including the nation's medical delivery system, payment type, disease pattern, and age distribution of patients that undergo THA. In future, the results of a large-scale nationwide study on primary THAs using CoC bearing surfaces in Korea will be reported. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aims. We investigated the local epidemiology of Developmental Dysplasia of the Hip (DDH), in order to define incidence, identify risk factors, and refine our policy on selective ultrasound screening. Methods. Data were recorded prospectively on all live births in the Exeter area from January 1998 to December 2008. We compared those treated for DDH with all other children. Crude odds ratios (OR) were calculated to identify potential risk factors. Logistic regression was then used to control for interactions between variables. Results. There were 182 children with DDH (245 hips) and 37,051 without. The incidence was thus 4.9 per 1000 live births. Female sex (adjusted OR 7.2, 95% CI 4.6–11.2), breech presentation (adjusted OR 24.3, 13.1–44.9), positive family history (adjusted OR 15.9, 11.0–22.9) and first or second pregnancy (adjusted OR 1.8, 1.5–2.3) were confirmed as risk factors (p<0.001). In addition, there was an increased risk with vaginal delivery (adjusted OR 2.7, 1.6–4.5, p<0.001) and postmaturity (OR 1.7, 1.2–2.4, p<0.002). Conclusions. One in 200 children born in our area requires treatment for DDH. Using both established and novel risk factors, we can potentially calculate an individual child's risk. Our work may contribute to the debate about selective versus universal ultrasound screening

Background. Vitamin D deficiency may increase predisposition to a number of paediatric orthopaedic conditions and the prevalence of vitamin D deficiency is increasing in children in developed countries. The aim of this study was to determine the epidemiology of vitamin D deficiency and insufficiency in children presenting to a regional paediatric orthopaedic service. We also examined the relationships between vitamin D status, social deprivation and ethnicity. Methods. Individuals, age < 18 years, presenting to the regional paediatric orthopaedic service at Southampton, UK from 2008 to 2010 were investigated. Deprivation index scores were calculated from indices of deprivation. Results. 187 children (97 male, 90 female, mean age 7.1 years) underwent serum 25-(OH) D level measurement. 82% were white British and 11% of Asian ethnicity. The calculation of the total depravation index for the whole cohort showed 34 (18%) of subjects were in quartile 1 (least deprived), 54 (29%) in quartile 2, 49 (26%) in quartile 3 and 50 (27%) in quartile 4 (Most deprived). 60 (32%) had vitamin D insufficiency with 25-(OH) levels < 50nmol/l and 15 (8%) had vitamin D deficiency. No relation ship was identified between vitamin D level and social depravation score. Conclusions. There is a need for awareness of the prevalence of vitamin D deficiency in the paediatric orthopaedic population presenting with bone pain and lower limb deformity before commencing ‘observation or orthopaedic surgical treatment’

Aims. We investigated the local epidemiology of Developmental Dysplasia of the Hip (DDH), in order to define incidence, identify risk factors, and refine our policy on selective ultrasound screening. Methods. Data were recorded prospectively on all live births in the Exeter area from January 1998 to December 2008. We compared those treated for DDH with all other children. Crude odds ratios (OR) were calculated to identify potential risk factors. Logistic regression was then used to control for interactions between variables. Results. There were 182 children with DDH (245 hips) and 37,051 without. The incidence was thus 4.9 per 1000 live births. Female sex (adjusted OR 7.2, 95% CI 4.6-11.2), breech presentation (adjusted OR 24.3, 13.1-44.9), positive family history (adjusted OR 15.9, 11.0-22.9) and first or second pregnancy (adjusted OR 1.8, 1.5-2.3) were confirmed as risk factors (p<0.001). In addition, there was an increased risk with vaginal delivery (adjusted OR 2.7, 1.6-4.5, p<0.001) and postmaturity (OR 1.7, 1.2-2.4, p<0.002). Conclusions. One in 200 children born in our area requires treatment for DDH. Using both established and novel risk factors, we can potentially calculate an individual child's risk. Our work may contribute to the debate about selective versus universal ultrasound screening

Introduction

Individuals with significant hip and knee trauma receive total knee (TKA) and total hip arthroplasty (THA) as definitive end-stage procedures. In Aotearoa, injury-related costs, including workers compensation, may be funded by ACC. With a steady increase of arthroplasty procedures in Aotearoa, we aim to understand the magnitude and characteristics of such procedures to inform future healthcare strategies.

Purpose: The prognosis of congenital hip displacement basically depends on the time of diagnosis and treatment. Recognising high-risk hips early remains a number one priority. We conducted a prospective study over a 20-year period from 1992 to 2002 to analyse the epidemiology of congenital hip displacement. Material and methods: The series included 1056 children with congenital hip disease (1491 hips). Epidemiological data, ultrasound and x-ray findings were recorded over 20 years. The objective was to identify risk factors and evaluate the impact of prevention measures. Results: The sex ratio showed female predominance, 6:1. The left hip was involved 1.8 times more often, with 41% bilateral involvement. Risk factors were major: family history (31%), breech presentation (25%), postural syndrome (12%); or minor: primiparity (54.4%), birth weight > 4 kg (9.2%). One or more major risk factors were found in 60.5% of the children and 30% had at least one minor risk factor. No risk factor was found in 40%. Screening efficacy improved with a rate of diagnosis before 4 months of 59% in 1983 and 96% in 2002. The number of hips discovered after the age of one year was 15% in 1983 and 6% in 2002. Discussion: The severity of the hip displacement is not influenced by risk factors nor bilateral involvement. Screening has enabled earlier diagnosis with a 37% increase in the rate of identification before the age of four months. This has been made possible by a systematic examination at birth and ultrasonography introduced in 1989. Conclusion: A regional map showing the paediatrician : maternity : general practitioner distributions is an important tool for screening campaigns. Despite adequate screening 40% of these children do not have any risk factor. Repeated examinations, communication and information exchange between healthcare professionals are the keys to success

Epidemiological data about tibial plateau and associated intra-articular proximal tibial fractures provides clinicians with an understanding of the range, variety, and patterns of injury. There are relatively few studies examining this injury group as a whole. We prospectively recorded all tibial plateau and intra-articular proximal tibial fractures occurring in our regional population of 545,000 adults (aged 15 years or older) in 2007–2008. We then compared our results with previous research from our institution in 2000. There were 173 fractures around the knee, 65 of these involved the tibial plateau. Median age was 59 years (IQR, 36.5–77.5 yrs). Tibial plateau fractures were more common in women (58.5%vs 41.5%). The median age of men was 37 years (IQr, 29–52 yrs) compared to women, 73 years (IQR, 57–82 yrs). Tibial plateau fractures accounted for 0.9% overall and 2.5% of lower limb fractures. Incidence was 1.2/10,000/yr (95% CI, 0.9–1.5). We have prospectively identified and described the epidemiological characteristics of tibial plateau fractures in adults from our region. We have identified a change to the epidemiology of these fractures over a relatively short time frame as the patients at risk age

The aim was to examine the descriptive epidemiology of Slipped Capital Femoral Epiphysis, with respect to geography and time. We extracted all children with a diagnosis of Slipped Capital Femoral Epiphysis from the Clinical Practice Research Database between 1990 and 2014 (24 years). CPRD is the world's largest database of primary care, which encompasses 8% of the UK population. CPRD was linked to Hospital Episode Statistics, and a validation algorithm applied to maximise sensitivity and specificity of the cases finding methodology. Poisson confidence intervals were calculated, and poison regression used. 596 cases of SCFE were identified. The internal validation algorithm supported a SCFE diagnosis in 88% cases. The age and sex distribution of cases mirrored that in the literature, offering external validity to the cases identified. There was no significant change in the incidence of SCFE over the 24-year study period, with the overall incidence being 4.8 cases per 100,00 0–16 year olds. There was no significant geographic variation in SCFE within the UK. There was a positive association with rising socioeconomic deprivation (p<0.01). There was no seasonal variation in presentation. This study found no evidence to support the common belief that SCFE incidence is increasing, and for the first time demonstrated an association with socioeconomic deprivation. The results are important for considering the feasibility of intervention studies, and offer insights into the disease aetiology

Aim: To describe the epidemiology of paediatric bone infections in a single health district in England with particular reference to incidence and the changing pattern of the disease. Method: Cases of chronic osteomyelitis and chronic regional multifocal osteomyelitis were excluded leaving 53 children diagnosed with acute haematological osteomyelitis (AHO) at a paediatric orthopaedic unit between January 2000 and December 2005. Patients were identified from the hospital coding system using the keywords ‘bone infection’ and ‘osteomyelitis’. The data were collected retrospectively from the patients’ hospital records and included demographic information, the delay between symptoms and presentation, clinical presentation, site of infection, organisms identified and laboratory results. Results: The mean age of presentation was 40 months (range 0.5–179). The highest age incidence was between 0–3 yrs. There was no sex predilection with 27 girls and 26 boys. The mean duration of symptoms before presentation was 3.4 days (range 0–14 days). The presenting symptoms were pain at the affected site in 100% of cases, pyrexia (temperature > 38°C) in 47.1%, swelling of the affected site in 47.1%. The commonest bone affected was the femoral metaphysis. The commonest bacterium isolated was staphylococcus aureus. WBC, CRP and ESR were elevated in 44%, 84% and 92.1 % of the cases respectively. Plain radiographs and bone scan demonstrated signs of osteomyelitis in 32.1% and 78.8 % respectively. Surgical intervention was required in 21 patients. Conclusions: The demographics and clinical presentation of AHO has not changed over the years. The commonest organism involved remains Staphylococcus aureus. ESR and bone scans were the most sensitive screening test for diagnosing the condition. Early initiation of third generation cephalosporin antibiotic therapy and surgical decompression, when necessary, was the mainstay of treatment

Aim: To quantify changes in epidemiology, in-patient treatment and outcome of hip fracture patients over seven-year period. Subjects and methodology: Retrospective randomised analysis of in-patient charts of patients with hip fractures admitted to a large 650-bed Acute District General Hospital in 1996 compared with 2003. The following data is gathered: Epidemiological data, baseline test data for anaemia and renal function, time to surgery from admission, post-operative complications, time to discharge from ward and functional outcome. Results: In 1996, the total number of admissions over 6 months was 144 compared to 160 in 2003 for the same time period. The mean age has increased from 83 years compared to 85 years in 2003. Median mental test score declined from 9 in 1996 to 6 in 2003. The mean co-morbidities rose from 1.7 in 1996 to 2.8 in 2003. 11% of patients were medically unfit for surgery in 1996 compared to 30% in 2003 resulting in delay in time to theatre. 33% of patients were admitted from nursing homes in 2003 compared to 22% in 1996. The mortality rate was 12% in 1996 compared to 18% in 2003. Conclusion: This study demonstrates that deteriorating pre-operative status in terms of age, ASA, mental test score and co-morbidities seems to have negated any of the system changes we introduced to improve our service. As patients with neck of femur fractures are often already suffering from other significant co-morbidities, the improvements in the overall health care system may not have an impact on the outcome of the patients concerned

Revision surgery is an important outcome of hip and knee arthroplasty among patients with osteoarthritis (OA). The objective of this study was to determine the risk of revision over time in a large, geographically defined population in North America, and to assess the effects of age, sex, and socioeconomic status (SES) on knee and hip revision rates in this population. We used data on admissions to all acute care hospitals in British Columbia (BC), Canada (population of four million people) from 1986 until 2004 (eighteen years of follow-up). Primary knee and hip replacement surgery for OA and revision procedures were identified using diagnostic (ICD-9, ICD-10) codes and surgical procedure codes. We excluded cases admitted due to injury or neoplasm. SES was assigned based on residential address linked to census data at the level of enumeration area (ecological variable), and analyzed according to quintiles or deciles of the distribution. In the analysis, we used Kaplan-Meier survival curves to describe the risk of first revision following first primary replacement surgery over time and parametric (Weibull) survival regression models to analyze the effects of joint (hip vs. knee) age, sex, and SES on revision rates. Death, emigration, and another primary joint replacement were treated as censoring events. Between 1986 and 2004, we observed 24,169 first primary hip replacements and 22,875 first primary knee replacements. In these patients, there were 1,313 hip revisions and 914 knee revisions following a primary replacement. The risk of revision at five, ten and fifteen years after primary replacement according to joint and sex were identified The overall risks were 10.1% for the hip and 8.7% for the knee at ten years, and 15.5% and 14.7%, respectively, at fifteen years. Risk of revision (%) following first primary joint replacement surgery Hip Knee Years Men Women Men Women 5 5.0 3.9 4.6 3.8 10 11.0 9.4 9.7 8.0 15 17.8 14.1 18.5 12.4 In a multivariate survival regression model including joint, age, sex, and SES, only age and sex were significantly associated with revisions. The hazard ratio was 1.2 for men compared with women (p< 0.0001). Revision rates were higher in younger persons, with hazard ratios increasing from 1.7 for age 70–79 (p< 0.0001) to 3.9 for age < 49 (p< 0.0001) compared with age 80+. After adjusting for age and sex, SES was not significantly associated with revision risk following primary hip or knee replacement surgery in this population (p=0.75). This is one of the largest and longest cohort studies in North America to look at the epidemiology of revision procedures following hip and knee replacement for OA. Higher rates in men and in younger persons are consistent with previous reports. The lack of association between revision risk and SES in BC is an important finding given current concerns about socioeconomic disparities in access to and outcomes of treatment for OA

We have attempted to describe the epidemiology of femoral fractures in children in the West Midlands region of the National Health Service in England. Our source of data was the Regional Hospital Episode Statistics database for the years 1991-2 to 2001-2. Cases were defined as emergency hospital admissions in patients aged under 16 years, with a diagnostic code of femoral fractures in any field, and resident in the West Midlands. Between 1991-2 and 2001-2, 3272 children aged under 16 years with femoral fractures were admitted to hospital. The crude incidence during this period decreased from 0.33 to 0.22 femoral fractures/1000/year. Those caused by traffic accidents decreased by 43%, and by falls by 29%. The peak age-gender-specific incidence (0.91/1000/year) was in two-year-old boys, and this was 50% higher than in the next highest age-gender group. In the first year of life, the incidence in boys and girls was the same. Thereafter the rate in boys exceeded that in girls, varying from 1.6 times at 11 years to 4.7 times at 14 years. Falls accounted for 49% of the fractures, varying from 77% in one-year-olds to 26% in eight-year-old children. Traffic accidents were responsible for 26% of fractures varying from 55% in ten-year-old to 2% in one-year-old children. Maltreatment was recorded in 1.3% of all cases, and in 8.5% of children under one year. Twice as many fractures were seen in May to August than in January (winter). The rates of fractures were associated with deprivation for all age-gender groups. Fractures of the shaft accounted for 58% of all fractures, varying from 70% in three-year-old to 34% in 13-year-old children. Our findings show that there has been a decrease in the incidence of femoral fractures during the 1990s and early 2000s. Two-year-old boys had twice the rate than any other single-year age-gender group. More deprived areas had much higher rates which suggests the potential for greater prevention. A relatively low rate of maltreatment was recorded compared with that in some other studies

Aim: To quantify changes in epidemiology, in-patient treatment and outcome of hip fracture patients over seven-year period. This data has provided a baseline of our local changes and provided information for local planning of health care provision for these patients, in terms of improved care pathways, treatment protocols, management with geriatricians, provision for discharge in the future. Subjects and methodology: Retrospective randomised analysis of in-patient charts of patients with hip fractures admitted to a large 650-bed Acute District General Hospital in 1996 compared with 2003. The following data is gathered: Epidemiological data, baseline test data for anaemia and renal function, time to surgery from admission, post-operative complications, time to discharge from ward and functional outcome. During this time interval we introduced a number of changes to our system of care such as: more junior doctors on the wards, more access to emergency operating time, better post-operative monitoring and care, and a move to a new hospital. Results: In 1996, the total number of admissions over 6 months was 144 compared to 160 in 2003 for the same time period. The mean age has increased from 83 years compared to 85 years in 2003. Median mental test score declined from 9 in 1996 to 6 in 2003. The mean co-morbidities rose from 1.7 in 1996 to 2.8 in 2003. 11% of patients were medically unfit for surgery in 1996 compared to 30% in 2003 resulting in delay in time to theatre. 33% of patients were admitted from nursing homes in 2003 compared to 22% in 1996. The mortality rate was 12% in 1996 compared to 18% in 2003. Conclusion: This study demonstrates that deteriorating pre-operative status in terms of age, ASA, mental test score and co-morbidities seems to have negated any of the system changes we introduced to improve our service. Some of our results are at variance with some national trends, highlighting the importance of undertaking this type of study locally. In our situation this was all the more surprising, given that demographically we have a relatively young population in Swindon compared to the national statistics. Performance and National League table results must take into account these demographic variances

We report the largest series of periprosthetic fractures in the literature, describing the changing epidemiology and predictors of outcome. A retrospective search of prospectively compiled trauma and elective electronic databases identified 630 periprosthetic fractures presenting to the study centre between 1995 and 2010. Patient demographics, comorbidities, socioeconomic status, mechanism of injury, fracture type, classification, method of fixation, and outcome were recorded using the patients’ notes. The General Register Office for Scotland was used to obtain the mortality status of the patients. There were 276 total hip replacements (THR), 123 total knee replacements (TKR), 117 hemiarthroplasty, and 114 “other” implants. The incidence of periprosthetic fractures increased significantly during the study period for all implants: THR (p<0.001), TKR (p<0.001), hemiarthroplasty (p=0.002), and other (p=0.003). The majority of fractures were fixed by open reduction and internal fixation (72%). This failed in 14% of THR, 15% of TKR, 21% of hemiarthroplasties, and 18% of “other” implants. Isolated independent predictors of failure of fixation, after multivariate regression analysis, were increasing age, deprivation, a past medical history of asthma or chronic obstructive airways disease, osteoporosis, and steroid use (p<0.05). Failure of fixation was associated with a significantly increased one year mortality rate (OR 12.5, p=0.003). Periprosthetic fractures involving THR and TKR are becoming more prevalent. Patient demographics can be used to calculate the risk of failure of fixation, and those with an increased risk may benefit from revision of their implant, and avert the associate morbidity of failure of fixation

Our aim is to study the epidemiology of delayed union and pseudarthrosis of femoral fractures which were treated in our clinic with intramedullary nailing technique and simultaneously to speculate for the application of the method and for the reasons which might guide to these complications. During a 36 month-period, from 1999 to 2001, 46 patients suffering femoral shaft fractures were treated in our clinic. They were 43 men and 3 women and their average age was 22.8 years. Twenty-eight fractures were in the right leg and 18 in the left. All patients underwent primary closed intramedullary locked nailing with AO type of nail, except 4 patients who also suffered a unilateral intertrochanteric fracture and were treated with AO-PFN nail. Reaming was done in 33 cases. No condition or disease able to inhibit fracture healing was observed. All patients were operated in the first three days after submission by the same team of surgeons. Thirty patients underwent static intranaedullary locked nailing and the rest dynamic from the beginning. The average time of post-operative follow up, clinical and radiological, was seven months. Thirty-three fractures were healed successfully in six months (mean: 4.2 months). In 10 cases delayed union was observed (mean: 7.2 months) and in the rest three pseudarthrosis. The last group underwent revision of the intramedullary nailing with an AO nail of greater diameter. Reasons for delayed union (21, 74%) and pseudarthrosis (6, 52%) are considered: a)soft tissues enclosed between the bony segments, b)lated nail dynamization, c)factors concerning the technique. Undoubtfully, closed intramedullary locked nailing is the method of choice for the surgical treatment of femoral fractures. However, fracture healing sometimes exceeds the usual period of 4–6 months. Unfortunately, whereas infrequently, the surgeon also faces pseudarthrosis which is a difficult to solve problem

Aims. The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. Patients and Methods. National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. Results. A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). . Conclusion. This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109–18

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures. . We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD). . We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group. . The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived. . These findings have important implications for public health and preventative measures. . Cite this article: Bone Joint J 2015;97-B:240–5

Rhabdomyosarcoma (RMS) is one of the typical tumors of childhood and adolescence, but it is exceedingly rare in adults. Unfortunately, the treatment success achieved over the years for pediatric RMS has not translated into better cure rates for adults, who continue to have a very poor prognosis (overall survival rates of only 20–40%). To better characterize adult RMS, we performed an analysis of all RMS cases registered on the Surveillance Epidemiology and End Results (SEER) public-access database collected from various geographic areas in the United States from 1973 to 2005. We analyzed 2600 patients, 1071 adults (> 19 years) and 1529 children (≤19 years). Tumors in adults were more likely to be at an unfavorable site (65% vs. 55%; P< 0.0001) and to have histologies that are unusual during childhood, particularly the pleomorphic subtype (19%) and not otherwise specified (43%). Regional and distant spread was not significantly higher in adults. Adults had significantly worse outcome than children (5-year overall survival 26.6% and 60.5%, respectively; P< 0.0001). Adults had significantly worse outcome also analyzing subset of patients with similar tumors (i.e. same histotype, same stage). The most significant difference was in localized disease; 5-year overall survival rates were 82.2% and 46.8%, respectively (P < .0001). Multivariate analysis showed that age, histologic subtype, primary site location, stage, treatment with surgery, and treatment with radiation were significant predictors of survival. However, alveolar subtype and unfavorable primary site lost significance when analysis was restricted to adults. In conclusion, our analysis confirmed that adult RMS was associated with a very poor outcome, especially in contrast to the significant improvements achieved in children treated contemporarily. The outcome for adults is consistently worse regardless of clinical characteristics, suggesting that factors other than an unfavorable clinical presentation might be involved in their unsatisfactory treatment results

Aims

The goals of this study were to define the risk factors, characteristics, and chronology of fractures in 5417 revision total hip arthroplasties (THAs).

Brazilian jiu-jitsu (BJJ) is a grappling-based martial art which can lead to injuries both in training and in competitions. There is a paucity of data regarding injuries sustained while training in Brazilian jiu-jitsu both in competitive and non-competitive jiu-jitsu athletes. Our primary objective was to determine the prevalence of injuries sustained during jiu-jitsu training and competition. Our secondary objectives were to describe the types of injuries, and to determine which participant and injury characteristics are associated with desire to discontinue jiu-jitsu following injury, and characteristics are associated with requiring surgery for an injury.

We conducted a survey of all BJJ participants at one club in Hamilton Ontario. We developed a questionnaire using focus groups, key informants and the previous literature. The questionnaire included questions on demographics, injuries in competition and/or training, treatment received, and whether the participant considered discontinuing BJJ following injury. The primary analysis was descriptive. The secondary analysis consisted of unadjusted logistic regression analyses to evaluate the association between selected demographic and injury patterns and those who considered quitting jiu-jitsu as a result of their injuries as a dependent variable.

Seventy BJJ athletes participated in this study (response rate 85%). The majority of respondents were male (90%), over the age of 30 years (58.6%), and junior trainees (white belts [37.2%] or blue belts [42.9%]). Ninety one percent of participants were injured in training and 60% of competitive athletes were injured in competitions. Significantly more injuries were sustained overall (p < 0 .001) for each body region (p∼0.001) in training in comparison to competition. Two-thirds of injured participants required medical attention, with 15% requiring surgery. Participants requiring surgical treatment were six and a half times more likely to consider quitting compared to those requiring other treatments, including no treatment (OR: 6.50, 95% CI: 1.53–27.60). Participants required to take more than four months off training were five and a half times more likely to consider quitting compared to those who took less time off (OR: 5.48, 95% CI: 2.25–13.38).

We identified that nine out of ten jiu-jitsu practitioners surveyed suffered injury while in training and the most severe injuries for the majority of practitioners occurring during training. The most common injuries identified involved the fingers, neck, knee, and shoulder, with the majority of respondents seeking medical or surgical treatment or requiring physiotherapy or rehabilitation. Potential participants in BJJ should be informed regarding significant risk of injury and instructed regarding appropriate precautions and safety protocols. BJJ practitioners and instructors should be especially cognizant of safety during training, where the majority of injuries occur.

Synovial sarcoma (SS) is a typical soft tissue sarcoma subtype crosswise between the pediatric and the adult age groups. No published data describes a different biology of SS when arising in adults as opposed to children, but different therapeutic strategies have been developed for pediatric and adult oncology protocols dealing with SS (in particular concerning the use of systemic therapy) and different overall outcomes have been reported by pediatric and adult groups. To better characterize the clinical features and outcomes of SS across the different age groups, we performed an analysis of all SS cases registered on the Surveillance, Epidemiology, and End Results (SEER) public-access database collected from various geographic areas in the United States, from 1983 to 2005. We analysed 1268 cases, 213 children/adolescents (≤18 years) and 1,055 adults. No major differences in stage distribution (localized, regional and distant stage) and clinical features were observed comparing the two age-groups, though a quite different pattern was recorded just for the small group of patients younger than 10 years (2.5% of cases, more extremity primaries, smaller tumors, mostly localized). The estimated 5-year cancer-specific survival was 83% for children/adolescents and 62% for adults (p< 0.001). Female sex, non-black race, tumors located in the extremities, localized tumors and tumors < 5 cm in size were associated with better survival. In multivariate analysis, adult patients had significantly higher mortality rates than children after adjusting for other variables. In conclusion, our analysis showed that children/ adolescents and adults with SS have a similar clinical presentation but a dissimilar outcome, suggesting that factors other than unfavorable clinical features might be involved in the unsatisfactory outcome of adult SS patients. It remains to be ascertained whether this difference may be related to biological variables or to historically-different treatment approach adopted in pediatric versus adult patients

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100 000 person-years. It was more common in women than in men (90 cases per 100 000 person-years in women and 83 per 100 000 person-years in men; p < 0.001). The highest incidence of 198 per 100 000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100 000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100 000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services. Cite this article: Bone Joint J 2014;96-B:350–3

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls. Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively. Cite this article: Bone Joint J 2014;96-B:366–72

Developmental dysplasia of the hip (DDH) refers to a spectrum of anatomical abnormalities. Despite various screening programs, delayed diagnosis still occurs. Delayed cases are more difficult to treat and can have poorer outcomes. Rural address, low socioeconomic status, and ethnicity have recently been associated with late presentation. The objectives of this study were to examine the incidence of DDH, as well as factors associated with delayed presentation in Saskatchewan.

Retrospective review of paediatric orthopaedic records from the tertiary referral centre in Saskatchewan was completed from 2008–2014. Variables collected included age at presentation, sex, birth order, birth presentation, birth complications, laterality, family history of DDH, postal code and treatment. Socioeconomic and geographic indicators were determined from postal code using the 2011 National Household Survey. Population level variables included income, ethnic origin, distance from referral centre and education. Associations were examined with bivariate and multivariate analysis.

There were 108 new presentations of DDH; 34 cases presented after age 3 months. Demographic data showed 83.3% of cases were female, 48.1% involved the left hip, 17.2% had a positive family history, 57.1% were first born, and 27.9% were breech. An estimated 5.6% of patients were Aboriginal. The mean age at presentation was 199.7 days. 48% of cases lived in the same city as the referral center. Late presenting cases lived on average 46.19 km farther from the referral centre and had a lower mean population, percent of adults with post-secondary education and income. However, none of these were statistically significant. No significant associations were found within the demographic data.

Overall incidence of DDH was not estimated due to few cases from southern areas of the province presenting to the tertiary referral center. The estimated incidence of DDH in the Aboriginal population from our sample was lower than previously reported in the literature. This association may be related to earlier swaddling practices, rather than Aboriginal ethnicity. There was a trend toward lower socioeconomic indicators and an increased distance from the referral centre in cases of late presentation, in keeping with recent literature exploring these factors. This suggests there may be deficits in the current selective screening protocols in North America. The study is limited by the retrospective nature of the research and the population level data obtained for certain variables. Future research to collect prospective individual level data may help elucidate important associations. Also, identifying any additional cases would increase the power to detect significant associations with late presentation, and allow an accurate estimate of overall incidence.

Aims

The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

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 Royal College of Surgeons of England (RCS) recently issued guidance regarding the use of re-operation rates in the re-validation of UK based orthopaedic surgeons. Currently, little has been published concerning acceptable rates of re-operation following primary surgical management of orthopaedic trauma, particularly with reference to re-validation.

We conducted a retrospective review of patients undergoing a clearly defined re-operation following primary surgical management of trauma between 1^st January 2010 and 31^st December 2011. 3688 patients underwent primary procedures while 83 (2.25%; 99%CI = 1.69 to 2.96%) required an unplanned re-operation. The mean age of patients was 46 years (range 2–98) with 46 (55%) males and a median time to re-operation of 34 days (IQR 12–134). Potentially avoidable re-operations occurred in 47 patients (56.6%; 99%CI = 42.6 to 69.8%) largely due to technical errors (46 patients; 55.4%; 99%CI = 41.4 to 68.7%), representing 1.27% (99%CI = 0.87 to 1.83%) of the total trauma workload. Within RCS guidelines 28 day re-operation rates for hip fractures, wrist fractures and ankle fractures were 1.4% (99%CI = 0.5 to 3.3%), 3.5% (99%CI = 0.8% to 12.1%) and 2.48% (99%CI = 0.7 to 7.6%) respectively.

We present novel work that has established baseline re-operation rates for index procedures required for revalidation of orthopaedic surgeons.

Aims

The aim of this study was to identify variables associated with time to revision, demographic details associated with revision indication, and type of prosthesis employed, and to describe the survival of hinge knee arthroplasty (HKA) when used for first-time knee revision surgery and factors that were associated with re-revision.

The accepted mechanism of traumatic limb amputation following blast is initial bone disruption due to the shock wave, with amputation completed by the blast wind; survival is considered unlikely. The high survival rate of traumatic amputees following explosion, from the current conflict in Afghanistan, is at odds with previous work.

We reviewed extremity injuries, sustained in Afghanistan by UK military personnel, over a 2 year period. 774 British servicemen and women sustained AIS >1 injuries, 72.6% of whom survived. No significant difference was found in the survival rates following explosive blast or gunshot (p>0.05).

169 casualties (21.8%) sustained 263 lower limb and 74 upper limb traumatic amputations. Amputations were more common in the lower than the upper limbs and more common in the extremity proximal bone. Bilateral lower limb amputations were more common than a unilateral lower limb amputation. The majority (99%) of major amputations were sustained as a result of explosion. 46.3% (74) of those who sustained a major amputation following explosion survived.

Rates of fatalities caused by explosion, or by small arms are not statistically different. Blast-mediated amputations are not universally fatal, and a significant number were through joint, calling into question previously proposed mechanisms.

Introduction

2010 marked a century since Perthes' disease was first described, but the aetiology and mechanism remain unknown. Worldwide, the incidence of Perthes' disease varies widely, yet this may be through differences in study design, population denominators or case ascertainment. It is suggested that differential exposure to adverse socioeconomic circumstances may be a key precipitant, although this remains the subject of debate. This work draws on several epidemiological studies that have sought to develop the understanding of Perthes' disease by examining a case register from Merseyside, discharge data from Scotland and the world's largest community disease register. A systematic review was performed to ensure a robustness and homogeneity between published studies in order to allow meaningful comparisons.

Aim

Over the past three years, roughly 100,000 hip and knee replacements have been performed by the Brazilian Public Healthcare System. Prosthetic joint infection (PJI) is expected to range between 1% to 10% after primary and revisions joint arthroplasties, respectively. So far, there have been no published national PJI data which would be helpful at developing local preventive strategies and guide surgeons and clinicians. We aimed at describing the epidemiological, clinical and microbiological PJI results of a national and collaboration study among infectious diseases specialists and orthopaedic surgeons, including academic, public and private institutions.

Aim and Methods

The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs).

Aims

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.

Purpose of study:

To analyse the bacteriological spectrum, identify most appropriate antibiotics for hand infections, and to characterize patterns and sites of hand infections. This information was collected against the background of a high prevalence of HIV infected patients and increasing antibiotic resistance.

Total hip replacement procedures provide a very effective treatment modality for a wide range of diseases and injures to joints.

The annual number of primary and surgeries has been increasing. In Region Emilia Romagna, 4000000 inhabitants, 4587 total hip replacements (THA) were performed in 1997 and the number raised up to 5410 in 2002 ( + 18%). Emiarthoplasties were respectively 1914 and 2215 (+ 16%). Parallely number of revision raised from 550 to 938 (+71%).

In 2003 incidence of primary THAs in Emilia-Romagna is 107/100.000 inhabitants, higher than mean national value (76/100000).

Data of both primary and revision surgeries are collected by RIPO (Register for Orthopaedic Prosthetic Implantology) that started its activity in Rizzoli Institute on January 1990 and in Regione Emilia-Romagna on January 2000. The recording of data is done for each joint replacement operation and it consists on the identification of the patient, information about diagnosis or reason for re-operation, surgical approach, antibiotic and antithromboembolic prophylaxis, perioperative complications. Acetabular, femoral and head components are separately registered, on the basis of stickers with catalogue numbers provided by manufacturers with the implants. Fixation of the components is recorded as well.

Among the purposes of the Register there are the identification of early prosthesis failures, the information of surgeons on the outcome of their patients, the creation of a benchmarking tool for consultants and the speedy identification of relevant patients if a particular prosthesis or a particular batch gives cause for concern.

As for Scandinavian registers, revision is used as an end-point in the analyses. On this basis it is possible to calculate survival curves either aggregated or stratified.

By Cox multivariate analysis it has been ascertained that risk factors in total hip arthroplasties are represented by sex (females have lower risk than males), by age (younger than 40 are more at risk than 40–70s, and older than 70 are less at risk than 40–70s) and by pathology (fracture, coxites and Paget diseases have higher risk than coxarthrosis).

Basing on these data, survival analysis was normalized and the influence of articular coupling and fixation of the components on prosthesis outcome have been evaluated.

It resulted that failures are more likely to occur when metal on metal, or metal on polyethylene or ceramic on polyethylene devices rather than ceramic on ceramic implants are implanted.

Similarly cemented and hybrid THAs fail at higher rate than uncemented ones. All data are referred to a 11 years follow-up.

At present time Kaplan Meier analysis indicates a survival rate of total hip arthroplasties performed at Istituto Rizzoli of nearly 90% at ten years follow-up (9717 primary implants, 435 failures).

Main reasons for revisions are aseptic loosening of the cup (33%),aseptic loosening of both components (18%), aseptic loosening of the stem (17%), deep infection (7.9%),dislocation (7.6%),prosthesis fracture (3%) etc. Aseptic loosening represent, therefore, the most frequent cause for revision.

Results obtained at Istituto Rizzoli fit in the benchmarking set by the British NICE (National Institute for Clinical Excellence) that states that the revision rate should be of 10% or less at 10 years.

To improve these results attention should be pointed on new models: hip prosthesis technology is continually changing, with new designs and techniques being introduced. There is a need to strike a balance between using prostheses with published long-term performance data, and the need to develop and improve hip prosthesis. A solution to this problem could be to entrust reference clinical centers the evaluation of the effectiveness of any new prosthesis for at least three years, before opening free distribution in standard orthopaedic units,as suggested by NICE. Only models that reach the ‘entry benchmark’ in adequately sized, well conducted observational studies, can be implanted with a good safety. At present time it is unlikely that clinical evaluation data on long term effectiveness is required by Notified Body for ‘CE’ marking, unless new materials are involved in the manufacture. This happens despite the fact that even small changes to existing prostheses can have a significant impact on implant performance and revision rate.

Other factors than the already discussed can influence the surgery outcome, and among these the volume of operations performed in the hospital, the ability of the surgeon and its confidence with the technique, the compliance of the patient. Only an overall view of the situation will allow to reach the goal of reduction of need for revision of total hip arthroplasties.

The objective was to compare susceptibility testing of all coagulase negative species (CNS) found in periprosthetic joint infections (PJI).

We conducted a multicentre retrospective study in a same area from 2011 to 2014, including 215 CNS strains.

Diagnosis of PJI was based on clinical, radiological and biological criteria. Microbiological criterion was at least 2 per-operative deep positive cultures with the same species of CNS. Identification and susceptibility testing were performed on automated Vitek2 (Biomérieux, France).

PJI localizations were 54% knees, 39% hips, 7% other sites.

CNS found in our study were by dicreasing order:

S. epidermidis (SE) 60%, S. capitis 11%, S. lugdunensis (SL) 10%, S. caprae 5%, S. warneri (SW) 4%, S. hominis (SHo) 3%, S. haemolyticus (SHa) 3%. Fifty two percent of CNS strains were meticillin (oxacillin) resistant and 31%, 33%, 41%, 20% were also resistant to clindamycin (CLI), trimethoprim-sulfamethoxazole (SXT), ofloxacin (OFX), rifampicin (RMP) respectively. Regarding CNS species, meticillin resistance was detected for 70% SE, 71% SHo and 71% SHa. SE was the most resistant species, with 34% of the strains resistant to CLI, SXT, OFX and RMP simultaneously. Half of SE and SHa were resistant to the reference treatment levofloxacin+rifampicin. Thirteen percent of CNS were resistant to teicoplanin and only 1% to vancomycin.

Susceptibility testing profiles are presented in table field.

In our study, S. epidermidis was the main species found in PJI. Emerging species like S. lugdunensis or S. caprae were found, with more susceptible antibiotic profiles. The most active antibiotics in vitro were daptomycin, linezolid, vancomycin and teicoplanin.

Infection of the musculoskeletal (MSK) system is a dreaded complication that seems to be on the rise. Many factors, such as resistant bacteria or poor host factors, may influence such rise. This increase leads to greater resource consumption, especially due to antibiotic (ATB) prescription. Strategies must be created to detect patients at risk and prevent such infections. Hospital administrators should be made aware of the costs and impact of MSK infections in order to understand the need to prevent such complications.

Therefore, our goal is to characterize the infected orthopaedic patient and evaluate the cost associated with ATB prescription in such cases.

This is a retrospective and descriptive study, based on patient record analysis of all patients treated at our department, from January 2013 to March 2015.

We identified 177 patients with a MSK infection and an isolated infectious agent.

There was no predominance of either sex. Approximately 50% of patients were aged between 66 and 85 years old.

Most frequent agents were MSSA (30,2%) and MRSA (21,8%), followed by Streptococcus species (8,9%) and Pseudomonas aeruginosas (7,1%). Although most patients were infected by a single agent, 18,6% had two or more causative agents isolated in cultures. Of those, 69,7% had either MSSA or MRSA as one of the isolated agents.

Most commonly affected area was the hip (39,5%), followed by the knee (23,2%) and ankle (21,5%). Nearly all patients had had prior surgery, with arthroplasty and osteosynthesis as the most common procedures (52,4% and 33,3%, respectively).

Infection related admission was responsible for a total of 6.116 hospital bed-days, with the majority of patients staying in hospital for up to 30 days (77,3%).

Total cost of hospital ATB administration was 61.365,61€, with approximately 346,7€ spent in each patient. This corresponds to 42,6% of the total cost of medication during hospital stay (144.146,1€ of total cost, with 814,4€ per patient).

The typical infected orthopaedic patient is aged 66 to 85 years old, was operated to his hip or knee, and either an arthroplasty or osteosynthesis was performed. Staphylococcus aureus remains the most common agent.

MSK infections have significant costs associated with their treatment, and clinical departments should periodically re-evaluate discharged patients in order to understand what groups are at risk of developing such a complication.

Only a correct identification of all these factors makes it possible to create a targeted preventive strategy, in order to reduce costs to the institution.