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

Aims. The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Method. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Results. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). Conclusion. OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry. Cite this article: Bone Joint J 2022;104-B(9):1073–1080

The interest in day-case hip arthroplasty is increasing; however, there are conflicting results regarding readmission risk, and little is known about patients’ attitude towards day-case surgery. We aimed to investigate differences in 30-day readmission rates between day-case patients and single-overnight-stay patients following total hip arthroplasty (THA) and explore patients’ attitude towards day-case surgery. From the Danish National Patient Register we identified 29,486 THAs (1353 day-case THAs and 28,133 single-overnight-stay THAs) performed between 2010 and 2020. Day-case surgery was defined as discharge on the day-of-surgery. Overnight admissions within 30 days of surgery were considered readmissions. Differences in readmission rates between day-case and single-overnight-stay patients were investigated using logistic regression adjusted for patient characteristics and year of surgery. In a single-center descriptive study, 2395 hip arthroplasty patients from 2016 to start-2023 answered a questionnaire on patient characteristics, attitude towards day-case surgery and patient-reported outcome measures (PROM). The overall 30-day readmission rate was 4.4% (CI: 4.2–4.6%) with no difference between day-case (4.4%) and single-overnight-stay THAs (4.4%) (odds-ratio: 1.2 [CI: 0.91–1.6]). In the descriptive study answers to the question whether patients were interested in being discharged on the day of surgery, were: “Yes” = 41%, “Do not know” = 20%, “No” = 39%. Patients responding “No” had lower preoperative PROM-scores, were older (“No” = 70.2 y vs. “Yes” = 65.3 y), and more often female (“No” = 72% vs. “Yes” = 52% female). Based on nationwide data from 2010–2020, day-case THA patients were not more likely to be readmitted compared to single-overnight-stay patients. However, most patients were not positive towards day-case surgery. While surgeons may consider day-case surgery to be safe, patients are not intuitively positive, indicating an attitude mismatch. To achieve high success rate and patient satisfaction in day-case surgery, shared-decision making initiatives within day-case surgery are needed

COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture. This nationwide cohort study included all patients aged >50 years with a hip fracture between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to population-level records of COVID-19 vaccination and testing. There were 13,345 patients with a median age of 82.0 years (IQR 74.0–88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34–0.48, p<0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12–3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk (OR 0.93, CI 0.53–1.60, p = 0.783). Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents essential data for future outbreaks

Aims. Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked disability, yet there is little robust evidence to guide treatment. Fundamental aspects of the disease, such as frequency, are unknown and consequently the desire of clinicians to undertake robust intervention studies is somewhat prohibited by a lack of fundamental knowledge. Methods. The study is an anonymized nationwide comprehensive cohort study with nested consented within the mechanism of the British Orthopaedic Surgery Surveillance (BOSS) Study. All relevant hospitals treating SCFE in England, Scotland, and Wales will contribute anonymized case details. Potential missing cases will be cross-checked against two independent external sources of data (the national administrative data and independent trainee data). Patients will be invited to enrich the data collected by supplementing anonymized case data with patient-reported outcome measures. In line with recommendations of the IDEAL Collaboration, the study will primarily seek to determine incidence, describe case mix and variations in surgical interventions, and explore the relationships between baseline factors (patients and types of interventions) and two-year outcomes. Discussion. This is the first disease to be investigated using the BOSS Study infrastructure. It provides a robust method to determine the disease frequency, and a large unbiased sample of cases from which treatment strategies can be investigated. It may form the basis for definitive robust intervention studies or, where these are demonstrated not to be feasible, this may be the most robust cohort study

Periprosthetic femur fracture (PPF) are heterogeneous, complex, and thought to be increasingly prevalent. The aims were to evaluate PPF prevalence, casemix, management, and outcomes. This nationwide study included all PPF patients aged >50 years from 16 Scottish hospitals in 2019. Variables included: demographics; implant and fracture factors; management factors, and outcomes. There were 332 patients, mean age 79.5 years, and 220/332 (66.3%) were female. One-third (37.3%) were ASA1-2 and two-thirds (62.3%) were ASA3+, 91.0% were from home/sheltered housing, and median Clinical Frailty Score was 4.0 (IQR 3.0). Acute medical issues featured in 87/332 (26.2%) and 19/332 (5.7%) had associated injuries. There were 251/332 (75.6%) associated with a proximal femoral implant, of which 232/251 (92.4%) were arthroplasty devices (194/251 [77.3%] total hip, 35/251 [13.9%] hemiarthroplasty, 3/251 [1.2%] resurfacing). There were 81/332 (24.4%) associated with a distal femoral implant (76/81 [93.8%] were total knee arthroplasties). In 38/332 (11.4%) there were implants proximally and distally. Most patients (268/332; 80.7%) were treated surgically, with 174/268 (64.9%) requiring fixation only and 104/268 (38.8%) requiring an arthroplasty or combined solution. Median time to theatre was longer for arthroplasty versus fixation procedures (120 vs 46 hours), and those requiring inter-hospital transfer waited longer (94 vs 48 hours). Barriers to investigating PPF include varied classification, coding challenges, and limitations of existing registries. This is the first study to examine a national PPF cohort and presents important data to guide service design and research. Additional findings relating to fracture patterns, implant types, surgeon skill-mix, and outcomes are reported herein

Aims. Joint arthroplasties may be associated with a blood loss, which necessitates transfusion. Especially, hip arthroplasties are highly associate with transfusion to compensate perioperative bleeding. Orthopaedic surgeons and patients have increasing concerns regarding complications of blood transfusions. Although various methods to reduce transfusions have been attempted in TJA, a high percentage of patients require a transfusion during and after the procedures. The purposes of this study were to evaluate the trends of the transfusion(transfusion rates, transfusion amounts, economic burden) in hip arthroplasties, using nationwide data from the National Health Insurance Service (NHIS). Patients and methods. We used data from nationwide claims database of Health Insurance Review Assessment Service (HIRA). The data managed by the NHIS were used to identify the 161,934 hip arthroplasties by 3 categories including bipolar hemiarthroplasty(BH), total hip arthroplasty(THA), and revision arthroplasty(RA) from 2007 to 2015. These 3 categories were classified using the operation code recorded in the requisition data of NHIS. The transfusion rates, transfusion amounts, proportion of transfusion, cost of each type of operation was investigated and stratified by age, gender, hospital type, and area in hip arthroplasties. The proportion of transfusion about whole blood, red blood cell, fresh frozen plasma, platelet, was also evaluated in hip arthroplasties. Results. The patients of hip arthroplasties who receive transfusion was observed 11,224/13,584 in 2007, 12,823/15,325 in 2008, 13,447/16.144 in 2009, 14,915/17,702 in 2010, 15,623/18,648 in 2011, 16,374/19,878 in 2012, 16,961/20,423 in 2013, 16,367/20,060 in 2014 and 16,116/20,170 in 2015. Total transfusion rate was 81.1% in 9 years data.(82.6% in 2007, 83.7% in 2008, 83.3% in 2009, 84.3% in 2010, 83.8% in 2011, 82.4% in 2012, 83% in 2013, 81.6% in 2014, 79.9% in 2015. The overall proportion of transfusion was 7% fresh frozen plasma, 12% platelet, and 77% RBC. The total amount of transfusion was 47,351 in 2007, 56.387 in 2008, 58,320 in 2009, 66,604 in 2010, 68,472 in 2011, 74,735 in 2012, 73,370 in 2013, 67,736 in 2014, and 62,749 in 2015. The average dose of transfusion is 4.1 times in bipolar hemiarthroplasty(343,815/ 83,729), 8.7 times in revision arthroplasty(35,044/4,024), 4.3 times in total hip arthroplasty from 2007 to 2015. Conclusion. In this nationally representative study of patterns of transfusion use in hip arthroplasty, we observed relatively high rates in the use of blood transfusion among patients undergoing hip arthroplasties regardless of many factors including patient, hospital, characteristics, compared with researches in other countries. The total amount of transfusion shows decreasing trends recently, however, it does not seem a big difference in transfusion rate

We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p <  0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay. . In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark. Cite this article: Bone Joint J 2014;96-B:1649–56

The aim was to determine the influence of COVID-19 on 30-day mortality in hip fracture. Secondary aims were to examine: (1) predictors of COVID-19 on presentation and later in the admission; (2) rate of hospital-acquired COVID-19; (3) predictive value of negative swabs on admission. A nationwide multicentre retrospective cohort study of all patients with hip fracture in all 17 Scottish hospitals in March-April. Demographics, blood results, COVID-19 status, Nottingham Hip Fracture Score (NHFS), management, length of stay (LOS), and 30-day mortality were recorded. 78/833 (9.4%) patients had COVID-19 (65 swab-proven). 30-day survival with COVID-19 was lower than without (65.4% vs 91%; p<0.001). COVID-19 within 7 days of admission (likely community-acquired) was independently associated with male sex (OR 2.34, p=0.040, CI 1.04–5.25) and COVID-19 symptoms (OR 15.56, CI 6.61–36.60, p<0.001). COVID-19 within 7–30 days (probable hospital-acquired) was independently associated with male sex (OR 1.73, CI 1.05–2.87, p=0.032), NHFS □7 (OR 1.91, CI 1.09–3.34, p=0.024), pulmonary disease (OR 1.68, CI 1.00–2.81, p=0.049), ASA □3 (OR 2.37, CI 1.13–4.97, p=0.022) and LOS □9 days (OR 1.98, CI 1.18–3.31, p=0.009). 38/65 (58.5%) of COVID-19 cases were probably hospital-acquired. The false negative rate of swabs on admission was 0% in asymptomatic and 2.9% in symptomatic patients. COVID-19 was associated with a threefold-increased 30-day mortality. Nosocomial transmission may have accounted for half of all cases. Identification of risk factors for having COVID-19 on admission, or acquiring COVID-19 later, may guide patient pathways. LOS was the only modifiable risk factor, emphasising the importance of high-quality, timely care

Aims

The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients.

Background: Isolated patellofemoral arthroplasty has gained new attention after recently published positive results. It is considered an intermediate treatment for the patient with isolated arthritis of the anterior compartment of the knee. Aim of this nationwide survey was to determine the current status of patellofemoral arthroplasty in Germany. Methods: All German departments of orthopaedic surgery, traumatology and general surgery with a yearly performance of at least fifty knee arthroplasties were asked to complete a standardized questionnaire. In the first part, surgeons were asked general questions about their department size, case numbers of knee arthroplasties per year and non-endoprosthetic treatment of isolated patellofemoral disorders. If patellofemoral arthroplasty was conducted, parameters concerning age, gender, duration of complaints, indication for surgery, surgical approach, type of endoprosthesis used, additional surgical treatments and failures were evaluated in the second part. Furthermore we asked for the reasons if no isolated patellofemoral arthroplasty was performed. Results: A total of 224 (30%) usable questionnaires were returned. Of 53420 knee arthroplasties performed per year, only 195 were isolated patellofemoral arthroplaties (0.37%). However, in 54 departments (24%), at least one isolated patellofemoral arthroplasty was performed with an average of 3.95 (1–20) procedures per year. The majority of patients were between 40 and 60 years old (40–60y: 56%; 20–40y: 8%, 60–80y: 35%, > 80y: 1%). Females were affected in 65% of patients. Etiology of isolated patellofemoral arthritis was believed to be idiopathic in 41% and traumatic in 8%. Patellofemoral dysplasia was held responsible in 47% and patellofemoral instability in 4% of cases. The main reason for failure and surgical revision was ongoing pain of the affected knee (40%). Negative attitude and disbelief towards the success of isolated patellofemoral arthroplasty were stated by the majority (62%) of non-users. A lack of appropriate indications was reported by 22% and missing know-how by 16%. Conclusions: Isolated patellofemoral arthroplasty has only little significance among surgeons performing knee arthroplasty in Germany. Although promising results were reported in the literature, the majority of surgeons do not believe in the success of the procedure

Although the clinical manifestation of ONFH is well summarized as forms of various stages, its etiology, natural history or epidemiology has not been clearly elucidated yet. With this study, we wanted to find out the estimated annual incidence, epidemiologic characteristics and the effect of known risk factors of ONFH. Therefore we can understand the disease better to provide optimal management to the patients. Among 133 189 patients who diagnosed as osteonecrosis of femoral head (ONFH) in database of national health insurance system in Korea from 2002 to 2006, three hundreds an eighty-two samples were randomly extracted with 5% error range in 95% confidence interval. With a structured worksheet, medical records and radiographs of each sample were reviewed at corresponding clinic or hospital by authors and trained orthopedic surgeons. With these data, we calculated the prevalence and associated risk factors. The mean number of annual requests was 23 466. Among 382 samples, two hundreds and seventy-four were confirmed to have ONFH. Diagnostic accuracy was 71.7 %. Diagnosis was more accurate when the patient was male or hospitalized. After the logistic regression analysis, calculated diagnostic accuracy during 2002 and 2006 was 60.3% (51 823/85 987). The annual predicted number of cases of ONFH during this period was 14 103. It corresponds to 28.91 patients per 100 000 populations. Alcohol abuse was noted in 45% and 22% was related to use of steroid. 37% showed bilateral involvement. Bone graft procedures in any kind was the most frequently performed joint preserving procedure. With this, the first epidemiologic study for ONFH in Korea, we estimated nationwide annual prevalence of ONFH as 28.91 per 100,000 populations during 2002 and 2006. There is an absolute male predominance. Alcohol abuse is the most frequent risk factors. We believe that this result can serve as a baseline data for understanding the epidemiology, clinical characteristics and treatment of ONFH

Aims: Nationwide, computer-based survey of all total joint arthroplasties performed in Finland has been carried out since January 1980. From these records a cohort of 9,443 patients, with 80,734 person-years, after primary operation with a total polyethylene-on-metal knee arthroplasty (TKA) has been followed up for cancer. In 1999 we published the material until December 31, 1996. The standardized incidence ratio (SIR) for all cancers was 0.98. The SIRs for non-Hodgkin lymphoma (1.40), Hodgkinñs disease (1.24), multiple myeloma (1.54) and prostate cancer (1.49) were increased, but only that of non-Hodgkin lymhoma was statistically signiþcant 3 to 10 years after the operation. The overall cancer risk after TKA done for primary osteoarthrosis appeared to be negligible. Material and methods: Follow-up for cancer was undertaken using the þles in the population-based, nationwide Finnish Cancer Registry, employing personal identiþcation numbers. Follow-up for cancer started at the date of þrst knee replacement and ended on emigration, death, or 31 December 2000, whichever occurred þrst. No subject was lost to follow-up. Standardized incidence ratios (SIRs) were calculated by dividing observed numbers of cases by expected numbers. Results: There were 2,001 men and 7,442 women left in the cohort to be followed-up. Numbers of person-years are now 15,679 and 650,552, respectively. The mean duration of follow-up per person was therefore 8,5 years. During the 21-year follow-up period, 358 cases of cancer occurred in the male subjects. The expected number was 349. In the female subjects 801 cases of cancer were observed vs. 804 expected. Combining data for men and women, the SIR for cancer at all sites was 1.00. SIRs were signiþ-cantly lower in relation to cancers of the lung (0.69), and colon (0.77). The incidence of risk of colon cancer was lower than would have been expected only in women (SIR 0.70). As far as cancers of the urinary organs is concerned, the SIR was within unity (SIR 1,03). The overall incidence of non-Hodgkin lymphoma (extranodal sites included) was elevated, but without any statistical signiþ-cance (SIR 1.22). The SIR values for multiple myeloma and leucemia have reduced to 0.80 and 0.53. Conclusions: We conclude, that this large nation-wide material could not establish any association between TKA and the all-over incidence of remote or adjacent cancers; on the contrary incidences of certain cancers were in fact lower than those reported in the formed material with four years less follow-up. All the alarming SIRs in the former material, especially those with non-Hodgin lym-phoma, urinary tract cancers and leucemia, have now reduced and are less than unity

Introduction. Although a previous hip fracture is one of the strongest predictors for the next one this risk might be modified by other factors. The goal of this analysis was to compute a simple algorithm to assess the individual risk for a contralateral hip fracture. Materials and methods. The analysis is based on a nationwide population-based Danish cohort study of 84,360 patients experiencing a hip fracture followed-up for 5 years. We a priori defined a set of 17 candidate parameters potentially associated with early contralateral hip fracture. We bootstrapped a stepwise augmentation procedure 10 times and selected five parameters that entered the model in all bootstrapping cycles and computed the individual risk for a contralateral fracture within two, three, and five years after the first incidence. Results. 12,349 patients (14.6%) experienced a contralateral hip fracture within five years. The strength of association were: female gender (Odds Ratio 1.58), alcohol abuse 1.57, living in a single household 1.10, no prescription of bisphosphonates 1.64, and comorbidity and Charlson Score values less than 2 2.20, between 3 and 4 1.76, 5 and more, 1.46 against no comorbidity. The probability of experiencing a second fracture ranged from 3.4% to 25.9%. Discussion. Once this instrument is validated in other cohorts it provides a rational basis for prophylactic augmentation or more aggressive pharmaceutical treatment

Aim: We determined 90 days mortality following primary total hip replacement (THR) and examined the impact of age and level of comorbidity. Methods: We used data from the nationwide population based Danish Hip Arthroplasty Registry between 1 January 1995 and 31 December 2004. Each THR patient was matched according to gender and age on the time of surgery with 3 persons from the general population randomly sampled using the Danish Civil Registration system, resulting in a total of 44 818 THA patients and 120 883 controls. We used a Cox regression analyses to computed age and comorbidity specific mortality rates (MR) and mortality rate ratio (MRR) with 95% Confidence Intervals (CI) for THR patients compared with the general population, as well as Number Needed to Harm (NNH). Results: The MRs for THR patients relative to those for the general population were highest in the patients younger than 60 years, corresponding to an adjusted MRR of 3.6 (95% CI: 2.2–5.5). Similar, an adjusted MRR was 1.2 (95% CI: 1.0–1.4) in patients aged 80 years and over. The THR patients younger than 60 years had more comorbidity than the controls, whereas distribution of comorbidity was equal in all other age groups. MRRs increase with comorbidity level for both THR patients and controls in all age groups. MRR for THR patients vs. controls within high comorbidity level aged below 60 years and aged 80 years and over was 3.5 (1.3–9.8) and 0.7 (0.5–0.9), respectively. However, hospitalisation with particularly cardio–og cerebrovasculaar disease before surgery increase mortality risk for both age groups, whereas hospitalisation with cancer increase mortality risk for patients younger than 60 years and decrease it for patients aged 80 years and over. Conclusions: Overall mortality of THR patients relative to those in the general population was higher 90 days after surgery. Our findings apply particularly for THR patients aged 10 to 59 and 80 years and over. Although THR patients aged 80 years and over with high comorbidity level had lower mortality than corresponding persons from the general population, some particular groups of medical condition prior to surgery is associated with increased mortality risk whereas other medical conditions are associated with decreased mortality risk. We should be careful in making clinical decisions based on the Charslon comorbidity index; subgroups analyses may be necessary. Further, we will present data on 90 days cause of death following primary THR and predictors for death, including age, gender and comorbidity (analyses are not finished yet)

Purpose:. To investigate treatment patterns and efficacy of postoperative strong opioids in patients who underwent total knee arthroplasty (TKA) in Korea. Methods:. A prospective, non-interventional study of 301 patients who underwent TKA and received strong opioids following patient controlled analgesia (PCA) was conducted by reviewing patient charts and diaries from 19 teaching hospitals. Clinical characteristics, strong opioid treatment patterns, efficacy of strong opioid on a scale of 0–10, and opioid-related adverse events (AEs) were investigated during hospitalization and at first outpatient visit. Safety analysis was conducted on 301 patients, and efficacy analysis was conducted on full analysis set (FAS) which consisted of all the patients who had at least 1 efficacy result among 301 patients. Results:. Among the FAS population of 298 patients, 86.9% were female, and mean age was 68.7 ± 7.5 years. Average duration of PCA was 4.3 ± 1.7 days, and average length of hospital stay including surgery was 16.3 ± 7.6 days. The mean duration of strong opioid prescription on a regular basis between PCA discontinuation and discharge was 10.3 ± 6.7 days. At the initial treatment with strong opioid following PCA, mean pain intensity score was 6.1 ± 2.1 upon movement and 4.2 ± 2.4 at rest. At discharge, mean pain intensity score was 4.1 ± 1.9 upon movement and 2.3 ± 1.8 at rest. Meanwhile, pain intensity score at the first outpatient visit was assessed only in 146 patients (49.0%) treated with opioid, and mean pain intensity scores upon movement and at rest were 3.5 ± 2.1 and 1.7 ± 1.8, respectively. Most frequently prescribed opioid was oral oxycodone (47.4%), followed by pethidine injection (17.2%), oral oxycodone/naloxone (12.6%), and transdermal fentanyl (12.0%). Additionally, the most frequently prescribed opioid on a regular basis was oral oxycodone (53.3%), and that on a PRN (pro re nata) basis was pethidine injection (48.4%). Among treatments, mean duration and mean daily dose of oral oxycodone during hospitalization were 6.1 ± 5.6 days and 13.9 ± 8.2 mg, 1.6 ± 1.2 days and 45.5 ± 24.5 mg for pethidine injection, 7.3 ± 5.3 days and 16.2 ± 7.3 mcg/hr for transdermal fentanyl, and 9.4 ± 8.0 days and 23.2 ± 16.8 mg/11.6 ± 8.34 mg for oral oxycodone/naloxone. At discharge, 150 patients (50.3%) were prescribed opioids. The most frequently prescribed strong opioid as discharge medications and their mean daily dose were 17.9 ± 10.5 mg of oxycodone (56.6%), 26.8 ± 17.0 mg/13.4 ± 8.5 mg of oxycodone/naloxone (17.1%), and 15.9 ± 6.1 mcg/hr of fentanyl (11.4%). Of 301 patients, 36 opioid-related AEs were reported in 26 patients (8.6%); the most frequently reported opioid-related AEs were nausea/vomiting in 13 patients (4.3%) experiencing 17 events, constipation in 10 patients (3.3%) experiencing 10 events, and sedation in 3 patients (1.0%) experiencing 3 events. Conclusion:. The first nationwide non-interventional study was conducted to investigate treatment patterns and efficacy of strong opioids in patients who underwent TKA. Among these patients, strong opioids provided favorable pain relief and were well tolerated at relatively low dose following PCA till the first outpatient visit

Aims: In 1999 we published a cohort of 24,638 polyethylene-on-metal total hip arthroplasty (THA) patients followed up for cancer, using Finnish Cancer Registry data, from 1980 to 1995. The number of person-years was then 173,022 (until 31st Dec, 1996). During follow-up, there were statistically significantly fewer cancers among the THA patients (standardized incidence ratio [SIR], 0.91; 95% confidence interval [Cl], 0.87–0.94). There was no significantly increased risk at any site, and for certain cancers that was even below the unity (lung and stomach). On the longer run, however, certain tendency for increased risk for cancer of the urinary bladder, myeloma, and leukemia could be observed; SIRs were greater than unity with the THA patients followed up 3 to 9 years. Further follow-up of the cohort is therefore needed. Methods: The follow-up of the same cohort, originally identified in the National Register of Arthroplasties, maintained by the National Agency for Medicines (primary THA with primary arthritis as the indication) was expanded with a four year period (from 1st of Jan 1997 to 31st of Dec 2000). Follow-up for cancer was undertaken using the files in the population-based, nationwide Finnish Cancer Registry, employing personal identification numbers. Follow-up for cancer started at the date of first hip replacement and ended on emigration, death, or December 31, 2001, whichever occurred first. Multiple cancers were taken account of in similar ways in relation to observed and expected numbers of cases. Results: After excluding revision and infective or systemic disease as indications for operation, there were 9,479 men and 15,157 women in the cohort followed. The updated numbers for person-years were 89,295 for males and 153,759 for females. The mean duration of follow-up was now 9,9 years. The total risk for cancer was now 0.93 (95%Cl 0.90–0.96) and that for stomach 0.89, for colon 0.90, lung 0.64, for urinary organs 1.01, and for connective tissues 0.88. The SIRs for non-Hogkin lymphoma, myeloma and leucemia were all under the untity, 0.88, 1.09 and 0.73, respectively, without any tendency for increased risk in the follow-up of plus ten years. Conclusions: These findings indicate that the risk of hematopoietic cancers is not increased after THA using polyethylene-on-metal prostheses. Expanding of the follow-up with four years did not markedly change the profile of the SIRs at any specific site, and contrary to our earlier report there were increased risk left of myeloma and leucemia with increased follow-up time. The SIRs associated with soft tissue cancers and bone sarcomas were not significantly different from unity. No sarcomas developed at the site of a prosthesis

The aim of this surgery was to determine current practice amongst orthopaedic surgeons in New Zealand with regard to Anterior Cruciate Ligament Reconstruction.

All current members of the NZOA were sent a questionnaire on the numbers and proportions of grafts performed, methods of fixation, operative technique and return to sport.

One hundred and ten of 140 questionnaires were returned completed. Ninety two orthopaedic surgeons were performing ACL reconstructions. Eight per cent performed patellar tendon grafts in preference to hamstring grafts, whereas 16% preferred hamstring over patellar tendon grafts. Almost 2000 patellar tendon grafts at an average of just over 20 per surgeon are performed each year compared to just over 500 hamstring grafts at an average of just over 15 per surgeon. Metal interference screws were the most common fixation device in patellar tendon and hamstring grafts.

Patellar tendon grafts are the most common grafts used for ACL reconstruction with 80 % of those surveyed preferring to use patellar tendon over hamstring grafts. Metal interference screws were the most common fixation device. There is reasonable consensus regarding return to activity and sport.

Purpose

The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures

Purpose: SWISSspine is a national health technology assessment (HTA) registry for ballon kyphoplasty (BKP) and total disc arthroplasty (TDA). It was initiated to evaluate the safety, efficiency and cost-effectiveness of these products. It is the first mandatory orthopaedic HTA registry of its kind in Switzerland. The aim is to generate evidence for a decision about reimbursement by the Swiss basic health insurance.

Methods: During the time between March 2005 until June 2008, 331 interventions with 391 treated levels in 320 patients have been documented. Data was collected in a prospective, observational multicenter mode. The preliminary timeframe for the registry is three years. Data collection is performed preoperative, at 6 weeks, 3 months, 6 months and 1 year followup as well as annually thereafter. Surgery and followup case report forms are administered by spinal surgeons. Comorbidity questionnaires, NASS and EQ-5D forms are completed by patients.

Results: Significant and clinically relevant reduction of back pain, improvement of quality of life and reduction of pain killer consumption was seen in the 1 year followup. Improvement of preoperative segmental kyhposis was achieved in the majority of cases. There were three symptomatic cement extrusions with radiculopathy documented.

Conclusion: BKP is a safe and effective treatment concerning pain reduction, quality of life improvement and pain killer consumption. The SWISSspine registry proved to be an excellent tool for evaluation of this new technology and its results lead to a permanent coverage of BKP by the basic health insurance.

BACKGROUND

Periprosthetic infection is the most challenging complication following total knee arthroplasty (TKA). Poor oral hygiene has been assumed as an important risk factor for TKA infection. We aimed to investigate whether the improvement of oral hygiene through dental scaling could reduce the risk of TKA infection.

The aim of this study was to determine if patient reported outcome scores for arthroscopic meniscectomy are adversely affected by the degree of knee osteoarthritis or patient body mass index (BMI).

All patients who underwent arthroscopic meniscectomy within the NHS in Scotland between 6th February and 29th April 2012 were audited as part of the Scottish Government Musculoskeletal Knee Arthroscopy Audit and were eligible for inclusion within this study. A total of 270 patients returned both their pre-operative and post-operative EuroQol 5Q5D5L descriptive questionnaire and Knee injury and Osteoarthritis Outcomes Scores. Patients were stratified according to BMI, degree of osteoarthritis, history of injury, and duration of knee symptoms.

Pre-operative to post-operative EuroQol index scores [0.642±0.253 to 0.735±0.277, median±SD] and Knee injury and Osteoarthrtis Outcome Scores [44.63±18.78 to 62.28±24.94, median±SD] improved across all patients (p<0.0001). This was irrespective of degree of BMI, history of injury, or duration of symptoms. There was no such improvement in patients with moderate to severe osteoarthritis. Those patients with a BMI >35 kg/m2 had lower post-operative scores than the pre-operative scores of those of BMI <30 kg/m2.

Arthroscopic meniscectomy is beneficial regardless of patient BMI, duration of symptoms, history of injury, or in the presence of mild arthritis.

Background

Level 1 studies for fracture management of upper extremity fractures remains rare. The influence of these studies on management trends has yet to be evaluated. The purpose of this study was to examine alterations in national trends managing mid-shaft clavicle and intra-articular distal humerus fractures (DHF) surrounding recent Level 1 publications.

Introduction: Despite the documented benefits, some countries have yet to agree on the establishment of a national arthroplasty registry.

Aim: The objective of this study was to determine the opinions regarding the establishment of an Irish National register from the Consultant Orthopaedic Surgeons and Senior Orthopaedic trainees in Ireland. We also aim to find the possible reasons why a national joint register has not been established in Ireland.

Method: We have undertaken a questionnaire study to sample the opinions of the Consultant orthopaedic surgeons and Specialist registrars(SR), regarding establishment of an Irish national joint register. The questions asked related to opinions about the setting up, purpose and maintenance of an Irish National Joint Register.

Results: A total of 79 responses were received of 114 questionnaires distributed (a 69% first response rate). 97% believe it is time we set up a registry, 94% will contribute and 81% say it should be made compulsory for unwilling Surgeons and Hospitals to participate. 82% of respondents felt the set up cost should be borne by the government (Health Service Executive). Only10% of consultants agreed that the IOA should be involved in the cost bearing. Despite the overwhelming support for a national register, privacy and liability issues were major concern. 58% of the total respondents strongly agree/agree that access to registry report by the general public can expose surgeons and Hospitals to a medicolegal loophole; hence access to database should be restricted. 78% strongly agree/agree that the registry data may be used as benchmarking tools by the administrators of health-care systems to discriminate methods, implants, surgeons and hospitals, which are found to be underperforming.

Conclusion: There are considerable logistical challenges involved in the establishment of any registry. Other countries have done it successfully, and the benefits are well documented. This subject has endorsement from the Professionals as demonstrated by this study. In a litigious society such as ours, legislation may be required to further protect the integrity of a national joint replacement registry to ensure that the data are used as intended—to serve as an early warning system for premature device failure and to improve outcomes for our patients.

AIM: Total hip replacement is the most successful procedure since 3 decades. In the last years a lot of new helpful implants were introduced to the market, minimal invasive procedures are presented in increasing numbers and the technique of navigation is introduced. On the other hand there is no scientific proof of the benefit of these procedures. The objective of this study was to collect data about the different procedures and the common used implants.

METHOD: In a countrywide anonymous survey, 250 German trauma surgery and orthopaedic surgery departments were asked about their MIS procedures and their treatment strategies.(August 2006)

RESULTS: 112 of the questionnaires have been returned so far. We found 82% of the surgeons doing minimal invasive THR, 18% are doing more than 50% of all procedures in MIS technique, while 45% of the colleagues report, that the patients never ask for the procedure. Most of the surgeons (58%) define “minimal invasive” as the preservation of muscle, tendons and soft tissue, 1% as the preservation of bone and 41% as the length of skin incision (6–12cm). The most common MIS approach is the lateral (45%), followed by the anterior approach (25%) and the modified Watson-Jones approach (21%) and the MIS dorsal approach (19%) (Some use more than 1 approach). For standard procedure (not minimal invasive) there is most used the Kocher approach (51%), followed by Bauer approach (29%) and Smith-Petersen/Watson-Jones (19%). 23% use navigation and 51% are convinced, there is no sense in that.

66% do not use articular resurfacing, 33% are using short implants.

CONCLUSION: While the technique of MIS in THR is whidespread in Germany, an exact definition is still missing. Patients don’t expect MIS as much as surgeons perform it. Out of the variety of approaches a standard still has to be defined.

For minimal invasive procedure there is most used a lateral approach, for standard procedure the Kocher approach. New implants are used by every third surgeon, navigation by every fourth surgeon.

Aim. Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life, and high healthcare costs. In 2009 a nationwide, multidisciplinary infection control program was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%. The primary aim was to investigate whether the PRISS project reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis. Method. We obtained data on patients undergoing primary THA in Sweden (n = 45,723 patients, 49,946 THAs), 2012–2014. Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks antibiotic consumption were reviewed to verify PJI diagnosis (n = 2240, 2569 THAs). Results. The cumulative incidence of PJI following the PRISS project was 1.2% [95% CI 1.1–1.3] as compared to 0.9% [95% CI 0.8–1.0] before. Cox regression models for the PJI incidence post PRISS indicates there were no statistical significance difference versus pre PRISS (HR 1.1 [95% CI 0.9–1.3]. There were similar time to PJI diagnosis after the PRISS project 24 vs 23 days (p=0.5). Conclusions. Despite the comprehensive nationwide PRISS project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher ASA class, and more fractures as indications, explain the PJI increase among primary THA patients

The December 2022 Trauma Roundup. 360. looks at: Anterior approach for acetabular fractures using anatomical plates; Masquelet–Ilizarov for the management of bone loss post debridement of infected tibial nonunion; Total hip arthroplasty – better results after low-energy displaced femoral neck fracture in young patients; Unreamed intramedullary nailing versus external fixation for the treatment of open tibial shaft fractures in Uganda: a randomized clinical trial; The Open-Fracture Patient Evaluation Nationwide (OPEN) study: the management of open fracture care in the UK; Cost-utility analysis of cemented hemiarthroplasty versus hydroxyapatite-coated uncemented hemiarthroplasty; Unstable ankle fractures: fibular nail fixation compared to open reduction and internal fixation; Long-term outcomes of randomized clinical trials: wrist and calcaneus; ‘HeFT’y follow-up of the UK Heel Fracture Trial

Studies and meta-analyses worldwide show an increased use of one-stage revisions for treating periprosthetic hip infections, often yielding comparable or better outcomes than two-stage revisions. However, it remains unclear if these successful results can be consistently achieved nationwide besides large centers. This observational cohort study used data from the German Arthroplasty Registry (EPRD) to compare the mortality and re-revision rates between one-stage (n=8183) and two-stage (n=657) first-time revision total hip arthroplasty (RTHA). Kaplan-Meier estimates were applied to evaluate the re-revision rate and cumulative mortality for RTHA. There was a significant difference in mortality between one-stage and two-stage RTHA (p=0.02). One-year post-surgery, the mortality rate was 9.4% for one-stage revisions and 5.5% for two-stage revisions. At the five-year follow-up, the mortality rate for one-stage revisions was 25.5%, compared to 20.0% for two-stage revisions. No significant differences (p=0.30) were found in re-revision rates between one-stage and two-stage revisions after one year (one-stage 16.5% vs. two-stage 13.5%) or five years (one-stage 21.6% vs. two-stage 20.8%). For multiple revisions, the mortality differences were even larger (p<0.001), with a one-year mortality rate of 12.8% for one-stage RTHA and 5.7% for two-stage RTHA. Despite the excellent results of one-stage RTHA in the literature from individual large centers, it shows a significantly higher mortality rate with equal re-revision rate compared to two-stage revision in the nationwide care besides large centers. Significant differences can already be seen within the first year, indicating an increased perioperative mortality for one-stage revision, which might be explained by longer surgery duration, blood-loss and patient selection or maybe a lack of experience concerning proper surgical debridement for one-stage revision. This illustrates the need to establish centers for joint-revision surgery that provide interdisciplinary care and high case numbers to improve perioperative outcomes

The December 2022 Research Roundup. 360. looks at: Halicin is effective against Staphylococcus aureus biofilms in vitro; Synovial fluid and serum neutrophil-to-lymphocyte ratio: useful in septic arthritis?; Transcutaneous oximetry and wound healing; Orthopaedic surgery causes gut microbiome dysbiosis and intestinal barrier dysfunction; Mortality in alcohol-related cirrhosis: a nationwide population-based cohort study; Self-reported resistance training is associated with better bone microarchitecture in vegan people

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?. Methods. Data consisting of annual International Classification of Diseases (ICD)-10 diagnosis codes from German medical institutions from 2009 to 2019, provided by the Federal Statistical Office of Germany (Destatis), were analyzed. Nonunion incidence was calculated for anatomical localization, sex, and age groups. Incidence rate ratios (IRRs) were determined and compared with a two-sample z-test. Diagnosis-related group (DRG)-reimbursement and length of hospital stay were retrospectively retrieved for each anatomical localization, considering 210 patients. Results. In 2019, a total of 11,840 nonunion cases (17.4/100,000 inhabitants) were treated. In comparison to 2018, the incidence of nonunion increased by 3% (IRR 1.03, 95% confidence interval (CI) 0.53 to 1.99, p = 0.935). The incidence was higher for male cases (IRR female/male: 0.79, 95% CI 0.76 to 0.82, p = 0.484). Most nonunions occurred at the pelvic and hip region (3.6/100,000 inhabitants, 95% CI 3.5 to 3.8), followed by the ankle and foot as well as the hand (2.9/100,000 inhabitants each). Mean estimated DRG reimbursement for in-hospital treatment of nonunions was highest for nonunions at the pelvic and hip region (€8,319 (SD 2,410), p < 0.001). Conclusion. Despite attempts to improve fracture treatment in recent years, nonunions remain a problem for orthopaedic and trauma surgery, with a stable incidence throughout the last decade. Cite this article: Bone Joint Res 2022;11(8):541–547

Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

The February 2023 Spine Roundup. 360. looks at: S2AI screws: At what cost?; Just how good is spinal deformity surgery?; Is 80 years of age too late in the day for spine surgery?; Factors affecting the accuracy of pedicle screw placement in robot-assisted surgery; Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery; Anterior cervical discectomy or fusion and selective laminoplasty for cervical spondylotic myelopathy; Surgery for cervical radiculopathy: what is the complication burden?; Hypercholesterolemia and neck pain; Return to work after surgery for cervical radiculopathy: a nationwide registry-based observational study

The February 2023 Oncology Roundup. 360. looks at: Is the number of national database research studies in musculoskeletal sarcoma increasing, and are these studies reliable?; Re-excision after unplanned excision of soft-tissue sarcoma is associated with high morbidity; Adjuvant radiation in atypical lipomatous tumours; The oncological outcomes of isolated limb perfusion and neoadjuvant radiotherapy in soft-tissue sarcoma patients - a nationwide multicentre study; Can low-grade chondrosarcoma be treated with intralesional curettage and cryotherapy?; Efficacy and safety of carbon ion radiotherapy for bone sarcomas: a systematic review and meta-analysis; Doxorubicin-polymeric meshes prevent local recurrence after sarcoma resection while avoiding cardiotoxicity; How important are skip lesions in Ewing’s sarcoma?; Improving outcomes for amputees: the health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees

Aims. This study sought to estimate the clinical outcomes and describe the nationwide variation in practice, as part of the feasibility workup for a National Institute for Health and Care Excellence (NICE) recommended randomized clinical trial to determine the optimal treatment of torus fractures of the distal radius in children. Methods. Prospective data collection on torus fractures presenting to our emergency department. Patient consent and study information, including a copy of the Wong-Baker Faces pain score, was issued at the first patient contact. An automated text message service recorded pain scores at days 0, 3, 7, 21, and 42 postinjury. A cross-sectional survey of current accident and emergency practice in the UK was also undertaken to gauge current practice following the publication of NICE guidance. Results. In all, 30 patients with a mean age of 8.9 years were enrolled over a six-week period. Of the 150 potential data points, data was captured in 146, making the data 97.3% complete. Pain scores were recorded at day 0 (mean 6.5 (95% confidence interval (CI) 5.7 to 7.3)), day 3 (4.4 (95% CI 3.5 to 5.2)), day 7 (3.0 (95% CI 2.3 to 3.6)), day 21 (1.2 (95% CI 0.7 to 1.7)) and day 42 (0.4 (95% CI 0.1 to 0.7)). Of the 100 units who participated in the nationwide survey, 38% were unaware of any local or national protocols regarding torus fractures, 41% treated torus fractures with cast immobilization, and over 60% of patients had follow-up arranged, both contradictory to national guidelines. Conclusion. We have demonstrated the severity, recovery trajectory, and variation in pain scores among children with torus fractures. We demonstrate excellent follow-up of patient outcomes using text messages. Despite national guidelines, there is significant variation in practice. This data directly informed the development of an ongoing nationwide randomized clinical trial – the FORearm Fracture Recovery in Children Evaluation (FORCE) study

Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622

Introduction. There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery. Methods. The BOSS Study is a series of nationwide observational cohort studies of pre-specified orthopaedic disease. All relevant hospitals treating the disease are invited to contribute anonymised case details. Data will be collected digitally through REDCap, with an additional bespoke software solution used to regularly confirm case ascertainment, prompt follow-up reminders and identify potential missing cases from external sources of information (i.e. national administrative data). With their consent, patients will be invited to enrich the data collected by supplementing anonymised case data with patient reported outcomes. The study will primarily seek to calculate the incidence of the rare diseases under investigation, with 95% confidence intervals. Descriptive statistics will be used to describe the case mix, treatment variations and outcomes. Inferential statistical analysis may be used to analyze associations between presentation factors and outcomes. Types of analyses will be contingent on the disease under investigation. Discussion. This study builds upon other national rare disease supporting structures, particularly those in obstetrics and paediatric surgery. It is particularly focused on addressing the evidence base for quality and safety of surgery, and the design is influenced by the specifications of the IDEAL collaboration for the development of surgical research

Aims. Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data. Methods. In the UK, the National Institute for Health and Care Excellence (NICE) advises that prompt early management of frozen shoulder is initiated in primary care settings with analgesia, physiotherapy, and joint injections; most people can be managed without an operation. Currently, there is variation in the type of joint injection: 1) CSI, thought to reduce the inflammation of the capsule reducing pain; and 2) HD, where a small volume of fluid is injected into the shoulder joint along with the steroid, aiming to stretch the capsule of the shoulder to improve pain, but also allowing greater movement. The creation of musculoskeletal hubs nationwide provides infrastructure for the early and effective management of frozen shoulder. This potentially reduces costs to individuals and the wider NHS perhaps negating the need for a secondary care referral. Results. We will conduct a multicentre RCT comparing CSI and HD in combination with CSI alone. Patients aged 18 years and over with a clinical diagnosis of frozen shoulder will be randomized and blinded to receive either CSI and HD in combination, or CSI alone. Feasibility outcomes include the rate of randomization as a proportion of eligible patients and the ability to use routinely collected data for outcome evaluation. This study has involved patients and the public in the trial design, dissemination methods, and how to include groups who are underserved by research. Conclusion. We will disseminate findings among musculoskeletal clinicians via the British Orthopaedic Association, the Chartered Society of Physiotherapy, the Royal College of Radiologists, and the Royal College of General Practitioners. To ensure wide reach we will communicate findings through our established network of charities and organizations, in addition to preparing dissemination findings in Bangla and Urdu (commonly spoken languages in northeast London). If a full trial is shown to be feasible, we will seek additional National Institute for Health and Care Research funding for a definitive RCT. This definitive study will inform NICE guidelines for the management of frozen shoulder. Cite this article: Bone Jt Open 2024;5(3):162–173

Aims. The aim of this study is to compare the effectiveness and safety of thromboprophylactic treatments in patients undergoing primary total knee arthroplasty (TKA). Methods. Using nationwide medical registries, we identified patients with a primary TKA performed in Denmark between 1 January 2013 and 31 December 2018 who received thromboprophylactic treatment. We examined the 90-day risk of venous thromboembolism (VTE), major bleeding, and all-cause mortality following surgery. We used a Cox regression model to compute hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome, pairwise comparing treatment with dalteparin or dabigatran with rivaroxaban as the reference. The HRs were both computed using a multivariable and a propensity score matched analysis. Results. We identified 27,736 primary TKA patients who received thromboprophylactic treatment (rivaroxaban (n = 18,846); dalteparin (n = 5,767); dabigatran (n = 1,443); tinzaparin (n = 1,372); and enoxaparin (n = 308)). In the adjusted multivariable analysis and compared with rivaroxaban, treatment with dalteparin (HR 0.68 (95% CI 0.49 to 0.92)) or dabigatran (HR 0.31 (95% CI 0.13 to 0.70)) was associated with a decreased risk of VTE. No statistically significant differences were observed for major bleeding or all-cause mortality. The propensity score matched analysis yielded similar results. Conclusion. Treatment with dalteparin or dabigatran was associated with a decreased 90-day risk of VTE following primary TKA surgery compared with treatment with rivaroxaban. Cite this article: Bone Joint J 2021;103-B(10):1571–1577

Use of anticoagulants for thromboembolic prophylaxis is strongly supported by evidence. However, the use of these medications beyond the prophylactic period is poorly understood. We identified anticoagulant naïve patients that underwent hip or knee replacement between 2012 and 2019 from an arthroplasty registry and probabilistically linked 3,018 surgeries with nationwide pharmaceutical claims data. Rates of anticoagulation use were examined during the early (<= 60 days post-discharge), mid-term (61–180 days post-discharge) and long-term (181–360 days post-discharge) periods. Multivariable logistic regression analysis was performed to identify patient- and surgery-related factors associated with long-term anticoagulant use. Anticoagulants were supplied to 20% of arthroplasties within 60 days of discharge, 7% between 61–180 days, and 10% between 181–360 days. Older age, obesity, increased comorbidity burden, a longer length of stay, occurrence of a complication necessitating anticoagulation and dispensation of an anticoagulant within 60 days of discharge were all risk factors for long-term anticoagulant use. Given the risks associated with unnecessary use of these medications, certain patients who are prescribed anticoagulants beyond prophylactic period may benefit from specialist medication review in the months following surgery

Aims. A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening. Methods. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group. Results. A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice. Conclusion. We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed. Cite this article: Bone Joint J 2023;105-B(2):209–214

The aim of this study was to measure the effect of hospital case volume on the survival of revision total hip arthroplasty (RTHA). This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTHA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTHA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTHA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. From 1999 to 2019, 13,020 patients underwent RTHA surgery in Scotland (median age at RTHA 70 years (interquartile range (IQR) 62 to 77)). In all, 5,721 (43.9%) were female, and 1065 (8.2%) were treated for infection. 714 (5.5%) underwent a second revision procedure. Co-morbidity, younger age at index revision, and positive infection status were associated with need for re-revision (p<0.001). The ten-year survival estimate for RTHA was 93.3% (95% CI 92.8 to 93.8). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was not significantly associated with lower risk of re-revision (HR1, 95% CI 1.00 to 1.00, p 0.073)). The majority of RTHA in Scotland survive up to ten years. Increasing yearly hospital case volume cases is not independently associated with a significant risk reduction of re-revision

Septic arthritis following anterior cruciate ligament reconstruction (ACLR) is a rare and serious complication. Previous studies have shown that septic arthritis is associated with inferior outcome of ACLR. Despite that, there is no standardized treatment protocol, and the course of the disease has mainly been studied within single institutions with a small number of patients. The aim of the present study is to describe the course of septic arthritis following ACLR in a large nationwide cohort. The hypothesis was that the clinical presentation of septic arthritis following ACLR varies according to the infectious agent. The present cohort represents patients with septic arthritis identified in a previous study that analyzed compensation claims reported to the Swedish national insurance company (Löf) in 2005–2014 (1). The diagnosis was confirmed by medical experts at Löf after review of medical records. We conducted a comprehensive analysis of the medical records as well as data available from the Swedish National Knee Ligament Registry (SNKLR) for the study group. The study involved 158 patients who received compensation due to developing septic arhtirits. 94 (59.9%) patients were infected with Coagulase negative staphylococci (CoNS), and 25 patients by Staphyolococcus Aureus (S.Aureus) (15.9%). There was a significant difference between the groups regarding Maximum CRP (p<0.001), and duration between ACLR and first washout operation (p<0.005). S.aureus group had the higest maximum CRP (281) and the shortest duration between ACLR and first washout operation (12 days). The Clinical presentation of septic arthritis following ACLR can vary according to the agent causing the infection, and low virulent agents are responsible for the majority of the infections. Clinicians need to be aware of these differences and consider them when making diagnosis or treatment decisions

Aims. Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD. Methods. In this retrospective, nationwide cohort study, the Korean National Health Insurance database from 1 January 2007 to 31 December 2018 was reviewed. Data were extracted for patients who underwent OD or PELD for LDH without a history of having undergone either procedure during the preceding year. Individual patients were followed for six months through their encrypted unique resident registration number. The primary endpoints were rates of reoperation and infection during the follow-up period. Other risk factors for reoperation and infection were also evalulated. Results. Out of 549,531 patients, 522,640 had undergone OD (95.11%) and 26,891 patients had undergone PELD (4.89%). Reoperation rates within six months were 2.28% in the OD group, and 5.38% in the PELD group. Infection rates were 1.18% in OD group and 0.83% in PELD group. The risk of reoperation was lower for patients with OD than for patients with PELD (adjusted hazard ratio (HR) 0.38). The risk of infection was higher for patients with OD than for patients undergoing PELD (HR, 1.325). Conclusion. Compared with the OD group, the PELD group showed higher reoperation rates and lower infection rates. Cite this article: Bone Joint J 2021;103-B(8):1392–1399

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. Method. This is a longitudinal collaborative study from 1st January 2000 to 31st December 2020, using ACC and New Zealand Joint Registry databases. Total cost was subcategorised into social and medical cost for analysis. Results. ACC funded 10179 TKA and 5611 THA, amounting to 918 million New Zealand Dollars. Most clients were between 55 and 65 years of age at time of surgery, with greater representation by Male sex and European prioritised ethnicity. Māori and Pacific peoples represent less than 10% of the study population. ACC identified requiring more than 182 days of workers’ compensation as a significant marker for needing additional supports. Risk of this was 21% for TKA and 11% for THA, with risk factors being younger age (RR 0.96), Male sex (TKA RR 1.12, THA RR 1.23), and heavy work-types (TKA RR 1.50, THA RR 1.57). Discussion. Supporting individuals with post-traumatic lower limb arthroplasty is costly. Workers’ compensation contributes to a significant proportion of social expenditure. Risk factors for increased cost utilisation can be used to highlight vulnerable clients and target interventions. Conclusions. This is one of few nationwide studies investigating the healthcare cost of post-traumatic lower limb arthroplasty. We need to focus on injury prevention, targeted treatment, and rehabilitation protocols to improve recovery and reduce time off work. These findings would be of interest to multiple stakeholders

Traumatic rotator cuff injuries can be a leading cause of prolonged shoulder pain and disability, and contribute to significant morbidity and healthcare costs. Previous studies have shown evidence of socio-demographic disparities with these injuries. The purpose of this nationwide study was to better understand these disparities based on ethnicity, sex, and socio-economic status, in order to inform future healthcare strategies. Accident Compensation Corporation (ACC) is a no-fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand (population in 2018, 4.7 million). Using the ACC database, traumatic rotator cuff injuries were identified between January 2010 and December 2018. Injuries were categorized by sex, ethnicity, age and socioeconomic deprivation index of the claimant. During the 9-year study period, there were 351,554 claims accepted for traumatic rotator cuff injury, which totalled over $960 million New Zealand Dollars. The greatest proportion of costs was spent on vocational support (49.8%), then surgery (26.3%), rehabilitation (13.1%), radiology (8.1%), general practitioner (1.6%) and “Other” (1.1%). Asian, Māori (Indigenous New Zealanders), and Pacific peoples were under-represented in the age-standardized proportion of total claims and had lower rates of surgery than Europeans. Māori had higher proportion of costs spent on vocational support and lower proportions spent on radiology, rehabilitation and surgery than Europeans. Males had higher number and costs of claims and were more likely to have surgery than females. There were considerably fewer claims from areas of high socio-economic deprivation. This large nation-wide study demonstrates the important and growing economic burden of rotator cuff injuries. Indirect costs, such as vocational supports, are a major contributor to the cost suggesting improving treatment and rehabilitation protocols would have the greatest economic impact. This study has also identified socio-demographic disparities which need to be addressed in order to achieve equity in health outcomes

Aims. This study aims to describe the pre- and postoperative self-reported health and quality of life from a national cohort of patients undergoing elective total conventional hip arthroplasty (THA) and total knee arthroplasty (TKA) in Australia. For context, these data will be compared with patient-reported outcome measures (PROMs) data from other international nation-wide registries. Methods. Between 2018 to 2020, and nested within a nationwide arthroplasty registry, preoperative and six-month postoperative PROMs were electronically collected from patients before and after elective THA and TKA. There were 5,228 THA and 8,299 TKA preoperative procedures as well as 3,215 THA and 4,982 TKA postoperative procedures available for analysis. Validated PROMs included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L; range 0 to 100; scored worst-best health), Oxford Hip/Knee Scores (OHS/OKS; range 0 to 48; scored worst-best hip/knee function) and the 12-item Hip/Knee disability and Osteoarthritis Outcome Score (HOOS-12/KOOS-12; range 0 to 100; scored best-worst hip/knee health). Additional items included preoperative expectations, patient-perceived improvement, and postoperative satisfaction. Descriptive analyses were undertaken. Results. For THA and TKA patients respectively, the patient profile was 2,850 (54.5%) and 4,684 (56.4%) female, mean age 66.8 years (SD 10.6) and 67.5 (SD 8.8), and mean BMI 29.9 kg/m. 2. (SD 7.7) and 32.5 kg/m. 2. (SD 7.0). The proportion of THA and TKA patients who reported their joint as ‘much better’ was 2,946 (92.6%) and 4,020 (81.6%) respectively, and the majority of patients were ‘satisfied’ or ‘very satisfied’ with their procedure (2,754 (86.5%) and 3,981 (80.8%)). There were 311 (9.7%) of THA patients and 516 (10.5%) of TKA patients who reported ‘dissatisfied’ or ‘very dissatisfied’ with their surgery. Conclusion. Large improvements in pain, function, and overall health were evident following primary THA and TKA. Approximately 10% of patients reported dissatisfaction with their surgery. Future analyses will focus on factors contributing to dissatisfaction after arthroplasty. Cite this article: Bone Jt Open 2021;2(6):422–432

Aims. The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone. Methods. This nationwide retrospective cohort study used data from the Diagnosis Procedure Combination database. We included patients aged ≥ 18 years who underwent surgery for hip fractures and received acetaminophen combined with NSAIDs (combination group), NSAIDs alone (NSAIDs group), or acetaminophen alone (acetaminophen group) preoperatively, between April 2010 and March 2022. Primary outcomes were in-hospital mortality and complications. Secondary outcomes were opioid use postoperatively; readmission within 90 days, one year, and two years; and total hospitalization costs. We used propensity score overlap weighting models, with the acetaminophen group as the reference group. Results. We identified 93,018 eligible patients, including 13,068 in the combination group, 29,203 in the NSAIDs group, and 50,474 in the acetaminophen group. Propensity score overlap weighting successfully balanced patient characteristics among the three groups, with no significant difference in in-hospital mortality rates observed among the groups (combination group risk difference 0.0% (95% CI -0.5 to 0.4%); NSAIDs group risk difference -0.2% (95% CI -0.5 to 0.2%)). However, the combination group exhibited a significantly lower risk of in-hospital complications than the acetaminophen group (risk difference -1.9% (95% CI -3.2 to -0.6%)) as well as a significantly lower risk of deep vein thrombosis (risk difference -1.4% (95% CI -2.2 to -0.7%)). Furthermore, total hospitalization costs were higher in the NSAIDs group than in the acetaminophen group (difference USD $438 (95% CI 249 to 630); p < 0.001). No significant differences in other secondary outcomes were observed among the three groups. Conclusion. The combination of acetaminophen with NSAIDs appears to be safe and advantageous in terms of reducing in-hospital complications. Cite this article: Bone Joint J 2024;106-B(8):849–857

Aims. The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty. Methods. This nationwide, retrospective cohort study used data from the Japanese Diagnosis Procedure Combination database. We included older patients (aged ≥ 60 years) who underwent THA or hemiarthroplasty after a femoral neck fracture, between July 2010 and March 2022. A total of 165,123 patients were included. The THA group was younger (mean age 72.6 (SD 8.0) vs 80.7 years (SD 8.1)) and had fewer comorbidities than the hemiarthroplasty group. Patients with dementia or malignancy were excluded because they seldom undergo THA. The primary outcome measures were mortality and complications while in hospital, and secondary outcomes were readmission and reoperation within one and two years after discharge, and the costs of hospitalization. We conducted an instrumental variable analysis (IVA) using differential distance as a variable. Results. The IVA analysis showed that the THA group had a significantly higher rate of complications while in hospital (risk difference 6.3% (95% CI 2.0 to 10.6); p = 0.004) than the hemiarthroplasty group, but there was no significant difference in the rate of mortality while in hospital (risk difference 0.3% (95% CI -1.7 to 2.2); p = 0.774). There was no significant difference in the rate of readmission (within one year: risk difference 1.3% (95% CI -1.9 to 4.5); p = 0.443; within two years: risk difference 0.1% (95% CI -3.2 to 3.4); p = 0.950) and reoperation (within one year: risk difference 0.3% (95% CI -0.6 to 1.1); p = 0.557; within two years: risk difference 0.1% (95% CI -0.4 to 0.7); p = 0.632) after discharge. The costs of hospitalization were significantly higher in the THA group than in the hemiarthroplasty group (difference $2,634 (95% CI $2,496 to $2,772); p < 0.001). Conclusion. Among older patients undergoing surgery for a femoral neck fracture, the risk of early complications was higher after THA than after hemiarthroplasty. Our findings should aid in clinical decision-making in these patients. Cite this article: Bone Joint J 2024;106-B(9):986–993

Aim. To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery. Method. This was a population-based, nationwide, cohort study. We included 74,771 from the Danish Multidisciplinary Hip Fractures Register (1) consisting of patients 65 years of age or older, who underwent surgery between January 1. st. 2005 and December 31. st. 2016 for all types of hip fracture. Cross-linkage with the Danish National Patient Register and The Danish Civil Registration system was made. Demographic data extracted included vital status, civil status, gender, age, Body Mass Index (BMI), fracture classification (AO/OTA 31A-C) and surgical procedures binary registered as joint replacement or internal fixation, Charlson comorbidity index (CCI) and secondary diseases not included in CCI. Outcome was reoperations due to deep SSI in accordance with the definition from Centre for Disease Control (2). We computed cumulative incidence rates and risk ratios (RR) by calendar year periods and by different risk factors, considering death as competing risk and adjusting for age, gender, CCI, fracture type and surgery type. Results. Within 365 days of primary surgery 2.1% of all hip fractures had undergone reoperation due to deep SSI. During the period 2005–2016, the incidence of reoperation due to SSI decreased from 2.7% to 1.7%, We could not identify differences in reoperation due to SSI within one year regarding gender, BMI or CCI. Patients aged above 85 had about 50% lower risk of being reoperated compared with the youngest age group; 65–74 years (RR: 0.5; 95% CI: 0.4:0.6). The RR for reoperation due to deep SSI was lower for patients with pertrochanteric or subtrochanteric fractures (AO/OTA: 31A1-3) versus femoral neck fractures (AO/OTA: 31B1-3), RR was 0.7 (95%CI: 0.7:0.8). However, RR for surgery type (joint replacement vs internal fixation) at 365 days was significantly lower for joint replacement, RR: 0.6 (95% CI: 0.6:0.7). Conclusions. This study shows reoperation risk due to SSI for all types of hip fractures of 2.1%. There was a 45% decrease in reoperation over time from 2005 to 2016. However, the risk of revision is still high, and further action in avoidance of SSI should be taken

Aims. We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires. Methods. During the first four weeks of the nationwide lockdown due to COVID-19, the objective impact of the pandemic on each trainee’s surgical caseload exposure was assessed using data from individual trainee logbook profiles in the deanery of the Republic of Ireland. Independent predictor variables included the trainee grade (ST 3 to 8), the individual trainee, the unit that the logbook was reported from, and the year in which the logbook was recorded. We used the analysis of variance (ANOVA) test to assess for any statistically significant predictor variables. The subjective experience of each trainee was captured using an electronic questionnaire. Results. The mean number of total procedures per trainee over four weeks was 36.8 (7 to 99; standard deviation (SD) 19.67) in 2018, 40.6 (6 to 81; SD 17.90) in 2019, and 18.3 (3 to 65; SD 11.70) during the pandemic of 2020 (p = 0.043). Significant reductions were noted for all elective indicative procedures, including arthroplasty (p = 0.019), osteotomy (p = 0.045), nerve decompression (p = 0.024) and arthroscopy (p = 0.024). In contrast, none of the nine indicative procedures for trauma were reduced. There was a significant inter-unit difference in the mean number of total cases (p = 0.029) and indicative cases (p = 0.0005) per trainee. We noted that 7.69% (n = 3) of trainees contracted COVID-19. Conclusion. During the COVID-19 pandemic, the mean number of operative cases per trainee has been significantly reduced for four of the 13 indicative procedures, as outlined by the JCST. Reassignment of trainees to high-volume institutions in the future may be a plausible approach to mitigate significant training deficits in those trainees worst impacted by the reduction in operative exposure

Aims. The primary aim was to determine the influence of COVID-19 on 30-day mortality following hip fracture. Secondary aims were to determine predictors of COVID-19 status on presentation and later in the admission; the rate of hospital acquired COVID-19; and the predictive value of negative swabs on admission. Methods. A nationwide multicentre retrospective cohort study was conducted of all patients presenting with a hip fracture to 17 Scottish centres in March and April 2020. Demographics, presentation blood tests, COVID-19 status, Nottingham Hip Fracture Score, management, length of stay, and 30-day mortality were recorded. Results. In all, 78/833 (9.4%) patients were diagnosed with COVID-19. The 30-day survival of patients with COVID-19 was significantly lower than for those without (65.4% vs 91%; p < 0.001). Diagnosis of COVID-19 within seven days of admission (likely community acquired) was independently associated with male sex (odds ratio (OR) 2.34, p = 0.040, confidence interval (CI) 1.04 to 5.25) and symptoms of COVID-19 (OR 15.56, CI 6.61 to 36.60, p < 0.001). Diagnosis of COVID-19 made between seven and 30 days of admission to hospital (likely hospital acquired) was independently associated with male sex (OR 1.73, CI 1.05 to 2.87, p = 0.032), Nottingham Hip Fracture Score ≥ 7 (OR 1.91, CI 1.09 to 3.34, p = 0.024), pulmonary disease (OR 1.68, CI 1.00 to 2.81, p = 0.049), American Society of Anesthesiologists (ASA) grade ≥ 3 (OR 2.37, CI 1.13 to 4.97, p = 0.022), and length of stay ≥ nine days (OR 1.98, CI 1.18 to 3.31, p = 0.009). A total of 38 (58.5%) COVID-19 cases were probably hospital acquired infections. The false-negative rate of a negative swab on admission was 0% in asymptomatic patients and 2.9% in symptomatic patients. Conclusion. COVID-19 was independently associated with a three times increased 30-day mortality rate. Nosocomial transmission may have accounted for approximately half of all cases during the first wave of the pandemic. Identification of risk factors for having COVID-19 on admission or acquiring COVID-19 in hospital may guide pathways for isolating or shielding patients respectively. Length of stay was the only modifiable risk factor, which emphasizes the importance of high-quality and timely care in this patient group. Cite this article: Bone Joint J 2021;103-B(5):888–897

Aim. National Joint Replacement Registries, which are important sources for periprosthetic joint infection (PJI) data, report an average PJI incidence ranging from 0.5 to 2.0%. Unfortunately, national registries including the Dutch Arthroplasty Register (LROI), are not specifically designed to register PJI. In the Netherlands, the LROI is a nationwide population-based registry with an overall completeness of more than 95%. 3. To ensure usability and reliability of PJI data from the LROI, it is important to evaluate the quality and completeness of these data. From 2013 onwards, eight hospitals in the South-East of the Netherlands, collected their PJI data in a detailed regional infection cohort (RIC), specifically designed for this purpose. This study aimed to determine the accuracy and completeness of PJI registration (hip and knee arthroplasty) in the LROI, by comparing the LROI with the RIC. Method. All patients registered with an acute PJI in the RIC between 2014–2018 were selected for the study and were matched with the LROI. According to the Workgroup of American Musculoskeletal Infections Society (MSIS), an acute PJI was defined as at least two phenotypically identical pathogens, isolated in cultures from at least two separate tissues, obtained from the affected peri-prosthetic tissue during the DAIR treatment (debridement, antibiotics, irrigation, and retention). Only PJI occurring within 90 days after primary hip or knee arthroplasty were included. The LROI data and completeness was based on the entered procedures and documented reason for revision infection, which was not specially based on the MSIS criteria. After checks on missing and incorrectly data, the completeness of registration in the LROI was calculated by comparing the number of registrations in the LROI with data from the RIC (gold standard). Results. Of the 639 primary total hip and knee arthroplasty with a suspected PJI registered in the RIC between 2014–2018, 352 cases met the definition of acute PJI. The overall incidence was 1%. When compared with the LROI, 164 of these cases were also registered in the LROI as PJI revision, resulting in a 53% underestimation of PJI for the LROI. Conclusions. LROI data on acute PJI shows a significant underestimation, which is comparable to scarce other literature sources. To ensure reliability and usability of national PJI data, a specifically part of the LROI has to be designed for registering PJI similar to the regional cohort

We present the development and results of a nationwide, prospective, observational follow-up programme including patient-reported outcome measures (PROMs) for the Swedish Hip Arthroplasty Register. The programme started in 2002 and has gradually expanded to include all units performing total hip replacement in Sweden. The self-administered PROMs protocol comprises the EQ-5D instrument, the Charnley class categorisation and visual analogue scales for pain and satisfaction. These current analyses include 34 960 total hip replacements with complete pre- and one-year post-operative questionnaires. Patients eligible for total hip replacement generally report low health-related quality of life and suffer from pain. One year post-operatively the mean EQ-5D index increased to above the level of an age- and gender-matched population, with a considerable reduction of pain (p < 0.001). Females, younger patients and those with Charnley category C reported a lower EQ-5D index pre-operatively than males, older patients and Charnley category A or B, respectively (all p < 0.001). In a multivariable regression analysis Charnley category C, male gender and higher age were associated with less improvement in health-related quality of life (p < 0.001). Nationwide implementation of a PROMs programme requires a structured organisation and effective data capture. Patients’ response rates to the Registry are good. The continuous collection of PROMs permits local and national improvement work and allows for further health-economic evaluation

Aims. The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA). Methods. This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTKA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTKA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTKA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. Results. From 1998 to 2019, 8,301 patients (8,894 knees) underwent RTKA surgery in Scotland (median age at RTKA 70 years (interquartile range (IQR) 63 to 76); median follow-up 6.2 years (IQR 3.0 to 10.2). In all, 4,764 (53.6%) were female, and 781 (8.8%) were treated for infection. Of these 8,894 knees, 957 (10.8%) underwent a second revision procedure. Male sex, younger age at index revision, and positive infection status were associated with need for re-revision. The ten-year survival estimate for RTKA was 87.3% (95% CI 86.5 to 88.1). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was significantly associated with lower risk of re-revision (HR 0.78 (95% CI 0.64 to 0.94, p < 0.001)). The risk of re-revision steadily declined in centres performing > 20 cases per year; risk reduction was 16% with > 20 cases; 22% with > 30 cases; and 28% with > 40 cases. The lowest level of risk was associated with the highest volume centres. Conclusion. The majority of RTKA in Scotland survive up to ten years. Increasing yearly hospital case volume above 20 cases is independently associated with a significant risk reduction of re-revision. Development of high-volume tertiary centres may lead to an improvement in the overall survival of RTKA. Cite this article: Bone Joint J 2021;103-B(4):602–609

Aim. Our aim was to evaluate cementless one-stage revision in chronic periprosthetic hip joint infection. Method and patients. The study was performed as a multicentre, proof-of-concept, observational study with prospective data collection. Inclusion of patients with a chronic periprosthetic hip joint infection (PJI) were followed by protocolled surgical treatment (cementless one-stage revision - the CORIHA protocol) at one of 8 participating departments of orthopaedic surgery between 2009 – 2014, and the patients enrolled in a 2-year follow-up program. A PJI were diagnosed based on adopted criteria from McPherson and Zimmerli. At the time of initiation of the study in 2009, the collaborating departments performed approximately one-fourth of all nationwide primary HJR and more than one-third of all revisions. In total 56 PJI patients with a median age of 72 years and a median pre-operative ASA score of 2 met the established eligibility criteria and accepted to participate; 31 (55%) were males. The cohort had a mean follow-up time of 4.0 years, with all patients followed for minimum 2 years. The primary outcome were relapse described as re-revision due to infection (regardless of considered as a relapse or new infection). This was evaluated by competing risk analysis (competing risks: aseptic revisions and death). Secondary, all-cause mortality was evaluated by survival analysis. The study was approved by the local Committees on Biomedical Research Ethics. Results. Five patients were revised due to relapse of infection. The cumulative incidence of re-revision due to infection was 8.9% (95% Confidence Interval 3.2–18.1). Seven patients had died in the follow-up period. None of these were believed to have been re-infected. The 1 and 5 year survival incidence was 96 (95% Confidence Interval 86–99) and 89 (95% Confidence Interval 75–95). Several complications were registered in the follow-up period: Three patients sustained periprosthetic fractures. Five patients had closed reduction due to dislocation - none have been open revised. Five patients sustained acute renal failure without long-term complications. One patient suffered an acute non-stemi myocardial infarction 8 days post-operatively, but with no major sequelae. One patient had soft-tissue revision of the wound following the CORIHA surgery, but is believed free of infection; One patient has severe irritation by the cables left from the extended osteotomy, but no further surgery is planned. Conclusions. We found that cementless one-stage revision in chronic hip PJI is a valuable treatment. This method has gained nationwide acceptance as first-line treatment strategy following this study

Aims. The aim of this study was to investigate the incidence, risk factors, and outcome of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in a nationwide cohort. Patients and Methods. All ACL reconstructions, primary and revision, that were recorded in the Swedish Knee Ligament Register (SKLR) between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare. The incidence of VTE was determined by entries between the day of surgery until 90 days postoperatively based on diagnosis codes and the prescription of anticoagulants. Risk factors, outcome, and the use of thromboprophylaxis were analyzed. Descriptive statistics with multivariate analysis were used to describe the findings. Results. The cohort consisted of 26 014 primary and revision ACL reconstructions. There were 89 deep venous thromboses (DVTs) and 12 pulmonary emboli (PEs) with a total of 95 VTEs (0.4 %). Six patients with a PE had a simultaneous DVT. The only independent risk factor for VTE was age greater than or equal to 40 years (odds ratio 2.31, 95% confidence interval 1.45 to 3.70; p < 0.001). Thromboprophylaxis was prescribed to 9461 patients (36%) and was equally distributed between those with and those without a VTE (37.9% vs 36.4%). All patient-reported outcome measures (PROMs) one and two years postoperatively were significantly lower in those with VTE. Conclusion. The incidence of VTE following ACL reconstruction is 0.4%, and the only significant risk factor is age. Patients with VTE had worse postoperative clinical outcome than patients without VTE. We recommend against the routine use of thromboprophylaxis, but it should be considered in older patients

Aims. Increasingly, patients with bilateral hip arthritis wish to undergo staged total hip arthroplasty (THA). With the rise in demand for arthroplasty, perioperative risk assessment and counselling is crucial for shared decision making. However, it is unknown if complications that occur after a unilateral hip arthroplasty predict complications following surgery of the contralateral hip. Patients and Methods. We used nationwide linked discharge data from the Healthcare Cost and Utilization Project between 2005 and 2014 to analyze the incidence and recurrence of complications following the first- and second-stage operations in staged bilateral total hip arthroplasty (BTHAs). Complications included perioperative medical adverse events within 30 to 60 days, and infection and mechanical complications within one year. Conditional probabilities and odds ratios (ORs) were calculated to determine whether experiencing a complication after the first stage of surgery increased the risk of developing the same complication after the second stage. Results. A total of 13 829 patients (5790 men and 8039 women) who underwent staged BTHAs were analyzed. The mean age at first operation was 62.9 years (14 to 95). For eight of the 12 outcomes evaluated, patients who experienced the outcome following the first arthroplasty had a significantly increased probability and odds of developing that same complication following the second arthroplasty, compared with those who did not experience the complication after the first surgery. This was true for digestive complications (OR 25.67, 95% confidence interval (CI) 13.86 to 46.08; p < 0.001), urinary complications (OR 6.48, 95% CI 1.7 to 20.73; p = 0.01), haematoma (OR 12.17, 95% CI 4.55 to 31.14; p < 0.001), deep vein thrombosis (OR 4.82, 95% CI 2.34 to 9.65; p < 0.001), pulmonary embolism (OR 12.03, 95% CI 2.02 to 46.77; p = 0.01), deep hip infection (OR 534.21, 95% CI 314.96 to 909.25; p < 0.001), superficial hip infection (OR 1574.99, 95% CI 269.83 to 9291.81; p < 0.001), and mechanical malfunction (OR 117.49, 95% CI 91.55 to 150.34; p < 0.001). Conclusion. The occurrence of certain complications after unilateral THA is associated with an increased risk of the same complication occurring after staged arthroplasty of the contralateral hip. Patients who experience these complications after unilateral hip arthroplasty should be appropriately counselled regarding their risk profile prior to undergoing staged contralateral hip arthroplasty. Cite this article: Bone Joint J 2019;101-B(6 Supple B):77–83

Aims. Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques. Methods. A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated. Results. The rate of joint-preserving procedures was significantly higher in patients aged < 50 years compared with those aged > 50 years (4.93% vs 1.52%; p < 0.001). For the overall cohort, rates of arthroplasty were far greater than those for joint-preserving procedures. THA was the most commonly performed procedure (291,114; 94.03%), while osteotomy (3,598; 1.16%), partial arthroplasty (9,171; 2.96%), core decompression (1,200; 0.39%), and bone graft (3,026; 0.98%) were performed markedly less frequently. The annual percentage of patients managed using a THA (93.56% to 89.52%; p < 0.001), resurfacing (1.22% to 0.19%; p < 0.001), and osteotomy (1.31% to 1.05%; p < 0.001) also decreased during the study period. Conclusion. We found that patients with ONFH have been most commonly managed with non-joint-preserving procedures. Our findings provide valuable insight into the current management of this condition and should increase efforts being made to save the hip joint. Cite this article: Bone Joint J 2020;102-B(7 Supple B):122–128

Aims. While use of large national clinical databases for orthopaedic trauma research has increased dramatically, there has been little study of the differences in populations contained therein. In this study we aimed to compare populations of patients with femoral shaft fractures across three commonly used national databases, specifically with regard to age and comorbidities. Patients and Methods. Patients were identified in the Nationwide Inpatient Sample (NIS), National Surgical Quality Improvement Program (NSQIP) and National Trauma Data Bank (NTDB). . Results. The distributions of age and Charleston comorbidity index (CCI) reflected a predominantly older population with more comorbidities in NSQIP (mean age 71.5; . sd. 15.6), mean CCI 4.9; . sd. 1.9) than in the NTDB (mean age 45.2; . sd. 21.4), mean CCI = 2.1; . sd. 2.0). Bimodal distributions in the NIS population showed a more mixed population (mean age 56.9; . sd.  24.9), mean CCI 3.2; . sd. 2.3). Differences in age and CCI were all statistically significant (p <  0.001). . Conclusion. While these databases have been commonly used for orthopaedic trauma research, differences in the populations they represent are not always readily apparent. Care must be taken to understand fully these differences before performing or evaluating database research, as the outcomes they detail can only be analysed in context. Take home message: Researchers and those evaluating research should be aware that orthopaedic trauma populations contained in commonly studied national databases may differ substantially based on sampling methods and inclusion criteria. Cite this article: Bone Joint J 2016;98-B:425–32

Aims. It has been suggested that cemented fixation of total hip arthroplasty (THA) is associated with an increased peri-operative mortality compared with cementless THA. Our aim was to investigate this through a nationwide matched cohort study adjusting for age, comorbidity, and socioeconomic background. Patients and Methods. A total of 178 784 patients with osteoarthritis who underwent either cemented or cementless THA from the Swedish Hip Arthroplasty Register were matched with 862 294 controls from the general population. Information about the causes of death, comorbidities, and socioeconomic background was obtained. Mortality within the first 90 days after the operation was the primary outcome measure. Results. Patients who underwent cemented THA had an increased risk of death during the first 14 days compared with the controls (hazard ratio (HR) 1.3, confidence interval (CI) 1.11 to 1.44), corresponding to an absolute increase in risk of five deaths per 10 000 observations. No such early increase of risk was seen in those who underwent cementless THA. Between days 15 and 29 the risk of mortality was decreased for those with cemented THA (HR 0.7, CI 0.62 to 0.87). Between days 30 and 90 all patients undergoing THA, irrespective of the mode of fixation, had a lower risk of death than controls. Patients selected for cementless fixation were younger, healthier and had a higher level of education and income than those selected for cemented THA. A supplementary analysis of 16 556 hybrid THAs indicated that cementation of the femoral component was associated with a slight increase in mortality up to 15 days, whereas no such increase in mortality was seen in those with a cemented acetabular component combined with a cementless femoral component. Conclusion. This nationwide matched cohort study indicates that patients receiving cemented THA have a minimally increased relative risk of early mortality that is reversed from day 15 and thereafter. The absolute increase in risk is very small. Our findings lend support to the idea that cementation of the femoral component is more dangerous than cementation of the acetabular component. Cite this article: Bone Joint J 2017;99-B:37–43

We compared the length of hospitalisation, rate of infection, dislocation of the hip and revision, and mortality following primary hip and knee arthroplasty for osteoarthritis in patients with Alzheimer’s disease (n = 1064) and a matched control group (n = 3192). The data were collected from nationwide Finnish health registers. Patients with Alzheimer’s disease had a longer peri-operative hospitalisation (median 13 days vs eight days, p < 0.001) and an increased risk for hip revision with a hazard ratio (HR) of 1.76 (95% confidence interval (CI) 1.03 to 3.00). Dislocation was the leading indication for revision. There was no difference in the rates of infection, dislocation of the hip, knee revision and short-term mortality. In long-term follow-up, patients with Alzheimer’s disease had a higher mortality (HR 1.43; 95% CI 1.22 to 1.70), and only one third survived ten years post-operatively. Increased age and comorbidity were associated with longer peri-operative hospitalisation in patients with Alzheimer’s disease. Cite this article: Bone Joint J 2015;97-B:654–61

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).

Introduction. The purpose of this study was to analyze trends in the surgical management of ON in recent years. Specifically, we evaluated the annual prevalences of: 1) joint preserving procedures (osteotomies and core decompression/grafts) and 2) joint non-preserving procedures (total hip arthroplasties [THAs], revision THAs, partial THAs) for the treatment of osteonecrosis of the femoral head (ONFH) between 2009 and 2016. Background. A total of 406,239 ONFH patients who were treated between 2009 and 2016 were identified from a nationwide database. Treatment procedures were extracted using ICD-9-CM and ICD-10-CM procedure codes. Annual rates of each of the above procedures were calculated and the trends in the procedure types were also evaluated. Chi-square tests were performed to compare the annual prevalence of each procedure. The mean annual prevalence over the 8-year study period was calculated for each procedure. Results. Throughout the study period, the number of joint preserving procedures steadily increased by 27%. In the earliest year studied, 2009, 41% (n=19,559) of the total procedures for ONFH were joint-preserving compared to 52% (n=13,715) in 2016. The rates of joint non-preserving procedures decreased (59 to 48%) over the same period (Figure 1). There was a decreasing annual prevalence of THAs (88 to 82%), revision THAs (2.0 to 1.4%), partial THAs (3.4 to 2.3%), osteotomies (4.2 to 3.2%), and core decompression (1.9 to 1.4%) throughout the study period (p<0.001). Throughout the 8-year period, THA was most commonly performed (mean annual prevalence 83%) whereas osteotomies (3.7%), partial THA (2.8%), core decompression/graft (1.9%), and revision THA (1.5%) were less commonly performed. Conclusion. In order to better understand trends in ONFH management, this study evaluated the annual prevalence of 5 commonly performed procedures. Although earlier data indicated decreasing rates of joint preserving procedure, this study found ONFH management has shifted more towards these procedures. For any tables or figures, please contact the authors directly

We evaluated the duration of hospitalisation, occurrence of infections, hip dislocations, revisions, and mortality following primary hip and knee replacement in 857 patients with Parkinson’s disease and compared them with 2571 matched control patients. The data were collected from comprehensive nationwide Finnish health registers. The mean follow-up was six years (1 to 13). The patients with Parkinson’s disease had a longer mean length of stay (21 days [1 to 365] vs 13 [1 to 365] days) and an increased risk for hip dislocation during the first post-operative year (hazard ratio (HR) 2.33, 95% confidence intervals (CI) 1.02 to 5.32). There was no difference in infection and revision rates, and one-year mortality. In longer follow-up, patients with Parkinson’s disease had higher mortality (HR 1.94, 95% CI 1.68 to 2.25) and only 274 (34.7%) were surviving ten years after surgery. In patients with Parkinson’s disease, cardiovascular and psychiatric comorbidity were associated with prolonged hospitalisation and cardiovascular diseases also with increased mortality. Cite this article: Bone Joint J 2014;96-B:486–91

Aims. The aims of this study were to compare the efficacy of two agents, aspirin and warfarin, for the prevention of venous thromboembolism (VTE) after simultaneous bilateral total knee arthroplasty (SBTKA), and to elucidate the risk of VTE conferred by this procedure compared with unilateral TKA (UTKA). Patients and Methods. A retrospective, multi-institutional study was conducted on 18 951 patients, 3685 who underwent SBTKA and 15 266 who underwent UTKA, using aspirin or warfarin as VTE prophylaxis. Each patient was assigned an individualised baseline VTE risk score based on a system using the Nationwide Inpatient Sample. Symptomatic VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT), were identified in the first 90 days post-operatively. Statistical analyses were performed with logistic regression accounting for baseline VTE risk. Results. The adjusted incidence of PE following SBTKA was 1.0% (95% confidence interval (CI) 0.86 to 1.2) with aspirin and 2.2% (95% CI 2.0 to 2.4) with warfarin. Similarly, the adjusted incidence of VTE following SBTKA was 1.6% (95% CI 1.1 to 2.3) with aspirin and 2.5% (95% CI 1.9 to 3.3) with warfarin. The risk of PE and VTE were reduced by 66% (odds ratio (OR) 0.44, 95% CI 0.25 to 0.78) and 38% (OR 0.62, 95% CI 0.38 to 1.0), respectively, using aspirin. In addition, the risk of PE was 204% higher for patients undergoing SBTKA relative to those undergoing UTKA. For each ten-point increase in baseline VTE risk, the risk of PE increased by 25.5% for patients undergoing SBTKA compared with 10.5% for those undergoing UTKA. Patients with a history of myocardial infarction or peripheral vascular disease had the greatest increase in risk from undergoing SBTKA instead of UTKA. Conclusion. Aspirin is more effective than warfarin for the prevention of VTE following SBTKA, and serves as the more appropriate agent for VTE prophylaxis for patients in all risk categories. Furthermore, patients undergoing SBTKA are at a substantially increased risk of VTE, even more so for those with significant underlying risk factors. Patients should be informed about the risks associated with undergoing SBTKA. Cite this article: Bone Joint J 2018;100-B(1 Supple A):68–75

Aims. Our unit was identified as a negative outlier in the national patient-reported outcome measures (PROMs) programme, which has significant funding implications. As a centre that carries out a high volume of unicompartmental knee arthroplasty (UKA), our objectives were: 1) to determine whether the PROMs programme included primary UKA when calculating the gain in Oxford Knee Score (OKS); and 2) to determine the impact of excluding primary UKA on calculated OKS gains for primary knee arthroplasty. Materials and Methods. National PROMs data from England (2012 to 2016) were analyzed. Inclusion of UKA cases in the national PROMs programme was determined using clinical codes. Local OKS gain was calculated for UKA and TKA and compared with the published PROMs results for 2012/13. Results. Use of the recommended codes for primary UKA excluded 99.6% of UKAs locally and 97% nationally from PROMs programme analysis. Inclusion of primary UKAs in PROMs analysis improved our OKS gain from 15.1 (below average) to 16.3 (above average) for 2012/13 for primary knee arthroplasty. Conclusion. Exclusion of UKA patients from the PROMs programme is a nationwide issue that potentially introduces bias when comparing OKS gain between centres. Where commissioning decisions are based on routinely collected data, it is imperative that the underlying methodology is appropriate to generate valid results

The aim of this study was to report the procedure survival and patient-reported outcomes in a consecutive series of patients <50yrs at the time of hip arthroplasty with a metal-on-metal hip resurfacing system who have progressed to a minimum of 10yrs follow-up. Patients presenting for treatment of degenerative conditions of the hip electing to undergo hip resurfacing were included in a clinical registry (N=226 patients; 238 procedures). Procedure survival was confirmed by crosschecking to the Australian Orthopaedic Association National Joint Replacement Registry and comparing to all procedures by other surgeons nationwide. Kaplan-meier survival curves with 95% confidence intervals were constructed, while patient-reported outcome measures were compared with t-tests and postoperative scores assessed with anchor analysis to age and gender-matched normative data. At mean follow up of 12 years, six cases were revised with a cumulative survival rate of 96.8% (95%CI 94.2–99.4) at 15 years. Majority of revisions were early (<3yrs) and occurred in females (N=4). Patient-reported general health, disease state, hip function and activity level maintained large improvements beyond 10 years post-implantation and were equal to or exceeded age and gender-matched normative data. Metal-on-metal hip resurfacing in males and females aged <50 years at time of surgery demonstrated a high rate of cumulative survival beyond 10 years follow up. The results demonstrate excellent outcomes in this age group

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?

In medical research and among health-care providers there has been a marked shift to a focus on patient-reported outcome (PRO) and how it is measured and analysed. In this study from the Swedish Hip Arthroplasty Register we present the development and results of a nationwide, prospective, observational follow-up programme including patient-reported outcome measures (PROMs). The programme started in 2002 and has gradually expanded to include all units performing THA surgery in Sweden. The self-administered PROM protocol comprises the EQ-5D instrument, the Charnley categorization and visual analogue scales (VAS) for pain and satisfaction. These current analyses include 34 960 THAs with complete pre- and one-year postoperative questionnaires. Patients eligible for THA generally report low health-related quality of life (HRQoL) and suffer from pain. One year post-operatively the mean EQ-5D index increased from 0.41 to 0.78 (p<0.001) which is above the level of an age- and gender-matched population. Pain was reduced from mean VAS 62 to 14 (p<0.001). Females, younger patients and those with Charnley category C reported lower EQ-5D index pre-operatively than males, older patients and Charnley A or B, respectively, did (all p<0.001). In a multivariable regression analysis Charnley category C, male gender and higher age were associated with less improvement in HRQoL (p<0,001). Patients' response rates to the Registry was 86% pre-operatively and 90% one year post-operatively. Nationwide implementation of a PROM programme requires a structured organization and effective IT solutions. The continuous collection of PROs permits local and national improvement work and allows for further health-economic evaluation

Aims. Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored. . Patients and Methods. The United States Nationwide Inpatient Sample (NIS) was used to identify patients undergoing elective TSA over a ten-year period. Between 2002 and 2012, 224 060 patients underwent elective TSA. Results. Among the identified patients who had undergone TSA, 12.4% had a diagnosis of a history of depression. A diagnosis of depression was twice as common in women compared with men (16.0% vs 8.0%, p < 0.001), and more frequent in those with low income and Medicaid insurance (p < 0.001). A diagnosis of depression was an independent risk factor for post-operative delirium (odds ratio (OR) 2.29, p < 0.001), anaemia (OR 1.65, p < 0.001), infection (2.09, p = 0.045) and hospital discharge to a placement other than home (OR 1.52, p < 0.001) . Conclusion. A history of clinical depression is present in 12.4% of patients undergoing elective TSA and the disease burden is projected to increase further in the future. Depression is often underdiagnosed and pre-operative screening and appropriate peri-operative management of patients is encouraged. Take home message: The awareness that clinical depression is associated with increased complications following total shoulder arthroplasty provides physicians an opportunity for early intervention in this at-risk population. Cite this article: Bone Joint J 2016;98-B:818–24

The Dawn Hip - An Effective Strategy to Improve the Management of Traumatic Hip Fractures. Introduction. Traumatic hip fractures are managed with nationwide standards, and are regularly audited and published. A previous audit last year at the William Harvey revealed 66% of hip fractures were operated within 48 hours, compared to the national average of 75%. We implemented a strategy to improve this target by introducing the ‘Dawn Hip’ - a hip fracture operation which is prepared for surgery at 8am on the Emergency (CEPOD) list. Methods. Over a two month period after the introduction of the ‘Dawn hip’, the number of hip operations and start time on the CEPOD list were audited. Performance data were extrapolated from the National Hip Fracture Database (NHFD) and compared nationally. Results. Three months prior to the ‘Dawn hip’ the mean start time of surgery on the CEPOD list was 9.50am. Two months since the introduction of the dawn hip, 67% of all trauma hip operations were done on the CEPOD list. The mean start time of the CEPOD list improved to 8.38am. Data from the NHFD revealed 81% of traumatic hip fractures were operated on within 48 hours, with the national average being 80%. Conclusion. This is an effective strategy which increases efficiency of existing resources and improves hospital services and patient care. It requires a multidisciplinary approach and participation from both managerial and clinical departments. This strategy not only optimises the care we provide for hip fractures, but also increases trauma list space for other pending trauma operations. By meeting nationwide targets, the trust is rewarded with cash incentives, which is used to further improve services. In the current economic climate, this represents a method of optimising healthcare, increasing cost savings and maximising productivity and efficiency

Background. As the number of total knee arthroplasties (TKA) being performed continues to increase, the number of potential failures requiring revision surgery would also be expected to increase. This study analyzed the trends in revision TKA (rTKA) from 2009 to 2016. Methods. The Nationwide Inpatient Sample (NIS) database was used to identify all rTKA by International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes. The diagnoses leading to revision, revision costs, patient and hospital characteristics, and major inpatient complications were compared between 2009 and 2016. Multivariate logistic regression analyses were used to calculate odds ratios (OR) for complications. Results. A total of 453,770 rTKA were performed between 2009 and 2016 (Table 1). The incidence of rTKA between 2009 and 2016 decreased by 4.3% among all age groups and decreased 5.9% in those over 65 years of age. The mean age at revision remained unchanged at 65 years, the mean Length of Stay (LOS) decreased 19.5% from 4.1 to 3.3 days (p<0.001), and the mean hospital costs increased 18.7% from $23,103 to $27,427 (p<0.001). Male to Female ratio remained unchanged with Females making up 58% of rTKA. The rTKA patients in 2016 versus 2009 had significantly lower odds of requiring a blood transfusion (OR 0.26, p<0.001). The rate of myocardial infarction remained unchanged in 2016 versus 2009 (4.1% vs. 4.0%, p=0.52), as did mortality (0.1% vs. 0.2%, p=0.089). Patients in 2016 were significantly less likely to be discharged to a skilled nursing facility (SNF) (26.5% in 2016 vs. 31.6% in 2009, p<0.001). A significantly larger share of rTKA were performed in urban teaching hospitals in 2016 (66.6% in 2016 vs. 41.5% in 2009, p<0.001). Mechanical loosening remained the most common reason for rTKA and increased from 19.7% in 2009 to 28.4% in 2016. Infection remained the second most common reason for rTKA (14.7% in 2009 vs. 12.2% in 2016). Instability was the third most common reason for revision in 2016 (10.7%) but direct comparison with 2009 could not be made since ICD-9 did not include this diagnosis. When comparing 2009 to 2014, an increase in revision rates was noted. Upon inclusion of 2015 and 2016 data, a decrease is noted. The primary limitation of this study is the challenge faced when comparing results from before and after the October 2015 transition of ICD-9 to ICD-10 codes. Conclusions. The incidence of rTKA had decreased slightly between 2009 and 2016 even while the volume of primary TKA continued to rise. Implant loosening became increasingly prevalent as a reason for revision and infection continued to plague patients after TKA. Positive trends were noted, such as decreased rates of blood transfusion, LOS and rates of discharge to SNF. Still, the revision burden remains large, costing approximately $1.4 billion annually and we must continue to attempt to improve outcomes in this patient population. For figures, tables, or references, please contact authors directly

Purpose: Many strategies have been reported for decreasing the cost of orthopaedic procedures, including negotiating lower prices with manufacturers and using lower-cost generic implants, but prosthetic waste has not been investigated. The purpose of this study was to characterize the present and potential future cost of intra-operative waste of hip and knee implants. Method: A regional prospective assessment of implant waste was performed from January 2007 to June 2008, evaluating the incidence and reasons for component waste, the cost of the wasted implants, and where the cost was absorbed (hospital or manufacturer). Using published data on nationwide arthroplasty volumes, the results were extrapolated to the whole of the United States. Finally, based on peer-reviewed estimates of nationwide arthroplasty volumes for the next 20 years, a projection was made about the future cost burden of implant waste. Results: Implant waste occurred in 79 of 3443 recorded procedures (2%), with the surgeon bearing primary responsibility in 73% of occurrences. The annualized waste cost was $109,295.35, with 67% absorbed by the hospital. When extrapolated to the whole of the United States, the annual cost to hospitals of hip and knee prosthetic waste is $36,019,000, and is estimated to rise to $112,033,000 in current dollars by the year 2030. Conclusion: This study discovered a notable incidence of intra-operative hip and knee implant waste, with the majority of cases attributed to the surgeon, and representing an important additional cost burden on hospitals. With arthroplasty rates projected to increase markedly over the next twenty years, this waste represents a potentially noteworthy target for educational programs and other cost containment measures in orthopaedic surgery

Aims. The purpose of this study was to analyze the incidence of the different ultrasound phenotypes of developmental dysplasia of the hip (DDH), and to determine their subsequent course. Patients and Methods. A consecutive series of 28 092 neonates was screened and classified according to the Graf method as part of a nationwide surveillance programme, and then followed prospectively. Abnormal hips were followed until they became normal (Graf type I). Type IIb hips and higher grades were treated by abduction in a Tübinger orthosis until normal. Dislocated hips underwent closed or open reduction. Results. Overall, 90.2% of hips were normal at birth. Type IIa hips (8.9%) became normal at a median of six weeks (interquartile range (IQR) 6 to 9). Type IIc and IId hips (0.67%) became normal after ten weeks (IQR 7 to 13). There were 19 type lll and eight type lV hips at baseline. There were 24 closed reductions and one open reduction. No late presentations of DDH were detected within the first five years of life. Conclusion. The incidence of DDH was eight per 1000 live births. The treatment rate was 1% (n = 273). The rate of first operations on the newborn hip was 0.86, and rate of open surgery was 0.04. The cumulative rate of open surgery was 0.07. The authors take the view that early identification and treatment in abduction of all dysplastic hips in early childhood reduces the rate of open reduction and secondary DDH-related surgery later in life. Cite this article: Bone Joint J 2018;100-B:1399–1404

Aims

Clear cell sarcoma (CCS) of soft-tissue is a rare melanocytic subtype of mesenchymal malignancy. The aim of this study was to investigate the clinical and therapeutic factors associated with increased survival, stratified by clinical stage, in order to determine the optimal treatment.

Increasing numbers of posterior lumbar fusions are being performed. The purpose of this study was to identify trends in demographics, mortality and major complications in patients undergoing primary posterior lumbar fusion. We accessed data collected for the Nationwide Inpatient Sample for each year between 1998 and 2008 and analysed trends in the number of lumbar fusions, mean patient age, comorbidity burden, length of hospital stay, discharge status, major peri-operative complications and mortality. An estimated 1 288 496 primary posterior lumbar fusion operations were performed between 1998 and 2008 in the United States. The total number of procedures, mean patient age and comorbidity burden increased over time. Hospital length of stay decreased, although the in-hospital mortality (adjusted and unadjusted for changes in length of hospital stay) remained stable. However, a significant increase was observed in peri-operative septic, pulmonary and cardiac complications. Although in-hospital mortality rates did not change over time in the setting of increases in mean patient age and comorbidity burden, some major peri-operative complications increased. These trends highlight the need for appropriate peri-operative services to optimise outcomes in an increasingly morbid and older population of patients undergoing lumbar fusion.

We assessed the age-related differences in the use of total shoulder arthroplasty (TSA) and outcomes, and associated time-trends using the United States Nationwide Inpatient Sample (NIS) between 1998 and 2010. Age was categorised as < 50, 50 to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were compared using logistic regression or the Cochran Armitage test. . The overall use of TSA increased from 2.96/100 000 in 1998 to 12.68/100 000 in 2010. Significantly lower rates were noted between 2009 and 2010, compared with between 1998 and 2000, for: mortality, 0.1% versus 0.2% (p = 0.004); discharge to an inpatient facility, 13.3% versus 14.5% (p = 0.039), and hospital stay > median, 29.4% versus 51.2% (p < 0.001). . The rates of use of TSA/100 000 by age groups, < 50, 50 to 64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively in 1998 (p < 0.001); and 0.65, 17.49, 75.27 and 49.05, respectively in 2010 (p < 0.001) with an increasing age-related difference over time (p <  0.001). Across the age categories, there were significant differences in the proportion: discharged to an inpatient facility, 3.2% versus 4.2% versus 14.7% versus 36.5%, respectively in 1998 (p < 0.001) and 1.8% versus 4.3% versus 12.5% versus 35.5%, respectively in 2010 (p <  0.001) and the proportion with hospital stay > median, 39.7% versus 40.2% versus 53% versus 69%, respectively in 1998 (p < 0.001) and 17.2% versus 20.6% versus 28.7% versus 50.7%, respectively in 2010 (p < 0.001). In a nationally representative sample, we noted a time-related increase in the use of TSA and increasing age-related differences in outcomes indicating a changing epidemiology of the use of TSA. Age-related differences in outcomes suggest that attention should focus on groups with the worst outcomes. . Cite this article: Bone Joint J 2015;97-B:1385–9

The aim of this study is to prepare for the introduction of the world’s first nationwide registry of all rotator cuff tears proceeding to operative management. Patient’s are scored pre-operatively and again at six and 12 months post-op using the Flex SF functional scale, pain scales and work and activity levels. A questionnaire is filled out by the operating surgeon on the day of surgery detailing pathology and the operative methods used. This study is a New Zealand Shoulder and Elbow Society initiative begun in 2007. New Zealand is ideally suited with a small, cohesive group of orthopaedic surgeons. Rotator cuff surgery is advancing rapidly with changes in surgical approach from open to arthroscopic, and repair methods from bone tunnels to various choices of anchors. A wide range of surgical methods are used within New Zealand, presenting an opportunity to use the large numbers generated by a registry to give valuable information guiding future treatment. The operation day questionnaire includes information on tear size, surgical approach, repair methods, biceps and AC joint pathology and rehabilitation. More than 100 patients have already been registered in the pilot study and a number have completed the six month questionnaire. These early results will be presented, along with important information for the large number of surgeons who will become involved when the nationwide registry commences

Aims

Achilles tendon re-rupture (ATRR) poses a significant risk of postoperative complication, even after a successful initial surgical repair. This study aimed to identify risk factors associated with Achilles tendon re-rupture following operative fixation.

While an increasing amount of arthroplasty articles report comorbidity measures, none have been validated for outcomes. In this study, we compared commonly used International Classification of Diseases-based comorbidity measures with re-operation rates after total hip replacement (THR). Scores used included the Charlson, the Royal College of Surgeons Charlson, and the Elixhauser comorbidity score. We identified a nationwide cohort of 134 423 THRs from the Swedish Hip Arthroplasty Register. Re-operations were registered post-operatively for up to 12 years. The hazard ratio was estimated by Cox’s proportional hazards regression, and we used C-statistics to assess each measure’s ability to predict re-operation. Confounding variables were age, gender, type of implant fixation, hospital category, hospital implant volume and year of surgery. In the first two years only the Elixhauser score showed any significant relationship with increased risk of re-operation, with increased scores for both one to two and three or more comorbidities. However, the predictive C-statistic in this period for the Elixhauser score was poor (0.52). None of the measures proved to be of any value between two and 12 years. They might be of value in large cohort or registry studies, but not for the individual patient. Cite this article: Bone Joint J 2013;95-B:1184–91

Introduction. Total knee arthroplasty (TKA) is a successful treatment for degenerative end stage knee arthritis. Younger patients who undergo TKA may face multiple revisions during their lifetime due to aseptic loosening, infection, and instability. The purpose of this study was to compare the early complication rates and revision free survivorship between age groups undergoing TKA in a nationwide database. Methods. The PearlDiver national insurance database was queried from 2007–2015 for all patients who underwent primary TKA. Kaplan-Meier Curve survival analysis and log rank test were performed to evaluate revision rates between age groups (<40, 40–49, 50–59, 60–69, 70–79, 80–89, and ≥90 years). Complication rates were compared to rates in the age 60–79 group using multiple logistic regressions controlling for baseline demographics and comorbidities. Results. There were 114,698 patients included in the analysis. Patients under age 40 years had higher rates of diabetes mellitus, inflammatory arthritis, drug abuse, and smoking status compared to the rest of the cohort (p<0.001). After controlling for baseline comorbidities using multiple logistic regressions, patients under age 40 and those age 40–49 had an increased rate of early mechanical complications (OR 2.84, p=0.01 and 2.95, p<0.001 respectively). 90-day readmission rates were significantly higher in the under age 40 group (OR 1.63, p=0.03). Revision free survivorship at 5 years was significantly worse in patients less than 60 years of age (77.2% in age <40 group, 88.9% in age 40–49 group, and 91.7% in age 50–59 group, p<0.01). Conclusions. Young patients under 40 years of age had a higher risk of early revision after TKA with 77% revision free survivorship at 5 years. Additionally, these patients have an increased risk of mechanical complications and readmission at 90 days. These outcomes may be used to shape preoperative counseling for the young patient

Aim. Early discharge of patients after joint arthroplasty leaves patients responsible for monitoring their postoperative wound by themselves. This might result in a delayed presentation of postoperative complications. The use of a mobile woundcare app by patients after arthroplasty might result in (1) earlier report of complications, (2) an increase in patient satisfaction and (3) insight in the incidence and duration of postoperative wound leakage. Therefore, the ease of use and perceived usefulness of using a postoperative mobile woundcare app in patients after joint arthroplasty was investigated. Method. A cohort study was conducted in 2017 in 2 Dutch Hospitals. Eligible cases were all consecutive patients that received an arthroplasty and who owned a smartphone. During the first 30 postoperative days, patients filled in daily reviews of their wound and took a photo of the wound. Based on the review, an underlying algorithm calculated daily a score that prompted a mobile alert if needed, which advised patients to contact the hospital. Patients filled in a form on day 30 and day 90 in order to document occurrence of any postoperative wound complication. On day 15 and 30, patients were requested to fill in a questionnaire evaluating the perceived usefulness and the ease of use of the App. Results. Of 127 eligible patients, 30 (24%) did not have a smartphone. Of the remaining 97 patients, 69 patients (71%) were included. Median age was 68 years (range 33–90 years). Forty-one patients (59.4%) used the app until day 30. On average, the app was used for 19.1 days (95% CI 16.6–21.5). Nine patients (13.0%) stopped using the app directly after the first or second day. The overall mean grade on a scale of 1 (strongly disagree) to 5 (strongly agree) was 4.2 for ease of use and 4.1 for perceived usefulness. The scores on day 30 were comparable to day 15. One patient (1.4%) developed a prosthetic joint infection. Conclusions. The introduction of a mobile woundcare app resulted in a high overall satisfaction rate with respect to ease of use and perceived usefulness. Daily use of the app did not lead to more stress. Currently, a nationwide cohort study is set up to implement the mobile woundcare app in Dutch hospitals to improve patient care. The app will then also be used to investigate the correlation between duration of postoperative wound leakage after joint arthroplasty and the development of prosthetic joint infection

The New Zealand Nationwide Rotator Cuff Registry is a first worldwide. An initiative of The NZ Shoulder and Elbow Society, work commenced on the project in July, 2005, and the Pilot Study involving four surgeons and 200 patients commenced in September 2007 and finished in February, 2009. The Nationwide Registry commenced in March, 2009, and by 30th June 520 patients had been recruited. This presentation will focus on the data for the first six months of the study. Analysis of data for the first four months showed that 71% of patients were male and 29% female. 62% involved the right shoulder. 88% of patients considered their shoulder problem accident-related. The rotator cuff repair was undertaken all-arthroscopic in 71 (13.8%), mini-open in 256 (49.6%), and open in 189 (36.6%). 95% were primary operations and acromioplasty was undertaken in 90%. Using Cofield’s classification, tear size was small (< 1cm in AP length) in 10%, 1–3cm in 62% and large in 28%. Average pain score did not correlate with AP tear size but the Flex-SF activity score deteriorated with tear size. The supraspinatus was normal in 6% and had a full thickness tear of all of the tendon in 39%, part of the tendon in 38% and had a partial thickness tear in 17%. The subscapularis was involved in 33% and infraspinatus in 28%. A labral tear was present in 8.4% and was repaired in 2.1%. Distal clavicle excision was undertaken in 9% of which 62% were open and 38% arthroscopic. The long head of biceps was normally located in 82%, subluxed in 11% and dislocated in 7%. In 47% of cases it was normal, in 42% damaged and in 11% ruptured. Tenodesis was undertaken in 24%, tenotomy in 19% and in 57% the tendon was left in situ. Double row repair was utilised in 60% and single row in 40%. Suture anchors were used in 78% of repairs, bone tunnels in 7% and a combination in 15%. The tendon quality was rated very well in 26%, good in 54% thin in 13% and poor in 7%. Postoperatively 42% were immobilised for 6 weeks, 24% for 4 weeks and 11% were not immobilised. A polysling was used in 56% and abduction pillow in 21%, and an ultrasling in 10%. Smoking and NSAID use will be compared in patient-derived outcome data at 6 months, one year and two years from surgery

Introduction: Femoral shaft fractures are commonly thought to be primarily associated with high energy trauma in young persons. Only limited attention has be given to low energy violence as a cause of these fractures among the elderly. National epidemiological data on characteristics of patients with femoral shaft fractures are lacking. So the purpose of this study was to analyse the incidence, admissions, causes of fracture and operations for these fractures on a nationwide basis in Sweden during 1998–2004. Patients and Methods: Data on all femoral shaft fractures were extracted from the Swedish National Hospital Discharge Registry. Sex- and age-specific fracture incidence, hospital admissions, mechanisms of injury and surgical procedures were analysed using descriptive analysis, linear-regression analysis and other methods as appropriate. Results: Over a period of 7 years, 6,409 patients with femoral shaft fractures were identified, corresponding to an annual incidence rate of 10 per 100,000 person-years. Men had a younger median age (27 years, IQR 12–68) than women (79 years, IQR 62–86) (p< 0.001). Females (54%) generated more admissions than males (46%). The incident rate ratio between men and women was 0.9 (p< 0.001). Most hospital admissions were generated among females by the 80–89 years age-group and among males < 10 years of age. 2% of the fractures were open shaft fractures. The total number of hospital admissions was stable during 1998–2004. The two major mechanisms of injury were falls on the same level (50%) and transport accidents (17%). A significant number of fractures occured among elderly patients after low-energy trauma. Osteosynthesis with femoral nail (54%) was the prefered operation, followed by osteosynthesis with plate and screws (16%), skeletal traction (14%) and external fixation (6%). Discussion: This nationwide study on femoral shaft fractures provides an update on incidence, admissions, external causes and surgical procedures. This information assists health care providers in planning hospital beds, surgical interventions and risk preventions. Moreover, these data can be used for power calculations for further clinical studies

Data of high quality are critical for the meaningful interpretation of registry information. The National Joint Registry (NJR) was established in 2002 as the result of an unexpectedly high failure rate of a cemented total hip arthroplasty. The NJR began data collection in 2003. In this study we report on the outcomes following the establishment of a formal data quality (DQ) audit process within the NJR, within which each patient episode entry is validated against the hospital unit’s Patient Administration System and vice-versa. This process enables bidirectional validation of every NJR entry and retrospective correction of any errors in the dataset. In 2014/15 baseline average compliance was 92.6% and this increased year-on-year with repeated audit cycles to 96.0% in 2018/19, with 76.4% of units achieving > 95% compliance. Following the closure of the audit cycle, an overall compliance rate of 97.9% was achieved for the 2018/19 period. An automated system was initiated in 2018 to reduce administrative burden and to integrate the DQ process into standard workflows. Our processes and quality improvement results demonstrate that DQ may be implemented successfully at national level, while minimizing the burden on hospitals.

Cite this article: Bone Jt Open 2022;3(9):716–725.

Aims

For the increasing number of working-age patients undergoing total hip or total knee arthroplasty (THA/TKA), return to work (RTW) after surgery is crucial. We investigated the association between occupational class and time to RTW after THA or TKA.

Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

Aims

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

Operative treatment of osteoporotic vertebral fractures seems to result in higher primary costs compared to conservative treatment. However it is still unclear whether the inpatient related follow-up costs don’t result in a different outcome. The aim of this analysis was a nationwide comparison of spine related inpatient treatments after balloon kyphoplasty versus conservative treatment of balloon kyphoplasty patients. Materials and Methods: 110 patients after conservative treatment and 141 patients after balloon kyphoplasty treated primarily between 2002 and 2005 in one center were followed up via a nationwide analysis of spine related inhospital treatment. Data from the Austrian DRG-system, which includes all inpatients treated in Austria have been used to identify admission of the target population between 2002 and 2006. Because no unique patient identifier is available in the data set, a matching according to data of birth, gender and postal code was used. Outpatient visits are not included. From these data the number of admissions, the length of stay and the scores can be determined. Furthermore each admission was classified as spine related or not. To calculate the exact follow up times the data were matched against the Austrian death registry. If a patient has died this data was used to calculate the follow up time otherwise December 31st 2006 was used. The mean age of the conservative group was 75.49 and of the kyphoplasty group 71.16 years. The total follow up time was 324.55 years(mean +standard deviation 2.92+−1.40) for the conservative and 354.25 (2.53+−0.96) for the kyphoplasty group. The shorter mean follow up interval for the kyphoplasty group is due to the fact that in the years 2004 and 2005 more patients have been treated by kyphoplasty. Results: The mean number of admissions in the kyphoplasty group is 0.779 or 0.308 per follow up year whereas in the conservative group these figures are approximately twice, namely 1.757 and 0.601. Considering the average length of stay the kyphoplasty group shows less inhospital days (9.2 per patient or 3.6 per follow up year), whereas in the conservative group this is 14.4 and 4.6 inpatient days. Finally the scores per admission in the follow up period are lower in the kyphoplasty group (3146 and 1243 DRG related treatment points) whereas in the conservative group these values are 3824 and 1308. Conclusion: These data show a strong superiority of kyphoplasty compared to conservative treatment of spine problems based on the data of one big hospital in Austria where 251 patients have been treated between 2002 and 2005. We demonstrate a long term superiority of balloon kyphoplasty compared to non-surgical treatment regarding inpatient treatments

Use of large databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and vary in methodology of data acquisition. The purpose of this study was to evaluate differences in reported demographics, comorbidities and complications following total hip arthroplasty (THA) amongst four commonly used databases. Patients who underwent primary THA during 2010–2012 were identified within National Surgical Quality Improvement Programs (NSQIP), Nationwide Inpatient Sample (NIS), Medicare Standard Analytic Files (MED) and Humana Claims Database (HAC). NSQIP definitions for comorbidities and surgical complications were queried in NIS, MED, and HAC using coding algorithms. Age, sex, comorbidities, inpatient and 30-day postoperative complications were compared (NIS has inpatient data only). Primary THAs from each database were 22,644 (HAC), 371,715 (MED), 188,779 (NIS) and 27,818 (NSQIP). Age and gender distribution were similar between databases. There was variability in the prevalence of comorbidities and complications depending upon the database and duration of post-operative follow-up. HAC and MED had twice the prevalence of COPD, coagulopathy and diabetes than NSQIP. NSQIP had more than twice the obesity than NIS. HAC had more than twice the rates of 30-day complications at all endpoints compared to NSQIP and more than twice the DVTs, strokes and deep infection as MED at 30-days post-op. Comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of infections and DVTs are captured when analysis is extended from inpatient stay to 30-days post-op. Amongst databases commonly used in orthopaedic research, there is considerable variation in complication rates following THA depending upon the database. It will be important to consider these differences when critically evaluating database research. Additionally, with the advent of bundled payments, these differences must be considered in risk adjustment models

Background: Screening modalities in early detection of DDH remain controversial worldwide despite of universal accessibility to ultrasound and despite of encouraging preliminary results reported about the Austrian and German general ultrasound screening programs. The goal of our investigations was to provide a long time survey on effects following the introduction of the ultrasound exam in prevention of DDH and to proof its beneficial medical and economic effects as well as to analyze possible adverse effects, when utilized by a general screening. Method: Nationwide data about ultrasound screening exams, sonographic follow up exams, frequencies of functional abductive treatment measures as well as hospitalizations due to DDH were requested by different Austrian health care providers. Through a representative recall over a time frame ranging partially back to 1980 a surveillance analysis is provided. The medical effectiveness of the screening was mainly assessed by the annual appearance of early late cases, representing open reductions (O.R.) upon the first two years of life. Other variables as the disease related incidence of age matched annual hospitalizations and the disease prevalence measured by non age matched hospitalizations in relation to the year specific population were analyzed. A cost benefit analysis was performed by comparing the treatment and diagnostic costs in the year before program start (1991) to the last year of surveillance (2004). Results: Since 1980 the functional treatment rate has continuously been reduced from approximately 12 percent to 3.23 percent in 2004. Early late cases (O.R.) due to DDH have been also diminished to an international competitive rate of 0.13 per 1000 newborns, while other age specific early surgical interventions could be almost eradicated. Current additional investments of the program figure only 16.94 € per newborn and embody approximately 1370 € per detection of one affected newborn. Control exams are contributing to roughly 25% of the calculated costs. Interpretation: By founding a nationwide program Austria has introduced a medically efficient screening modality to reduce early late cases and to limit treatment of DDH exposed children to less invasive measures by early diagnosis. In contrary to suspicions of possible adverse effects of such screening, overtreatment has been abandoned while the functional treatment rate has sunken to an acceptable level. Costs saving effects have been already realized on the treatment side. Further savings shall be realized by limiting an unacceptable rate of control exams

The presence of obesity has negative influence on the progress of osteoarthritis and increases the risk of undergoing a primary THA at an earlier age. However, the correlation of BMI and the risk for postoperative complications, revision surgery and infection rate is still controversial. In the largest cohort to this date, we used the German insurance claims database to evaluate the correlation of BMI and the risk of postoperative complications, mortality and revision rates following primary THA. Using nationwide billing data of the German health-care insurance for inpatient hospital treatment, we identified patients over the age of 20 years who had undergone either THA or short-stem THA between January 2012 and December 2014. BMI was classified into four groups (< 30 kg/m², 30 to 34.9 kg/m², 35 to 39.9 kg/m², > 40 kg/m²). In all patients, the 90-day complication, mortality and revision rates were calculated. Furthermore, all complications and revisions were determined at a latest follow-up of 1 year. We used multivariable logistic regression to model the odds of complications as a function of BMI groups. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated. A total of 131,576 total hip arthroplasties in 124,368 patients were included for final analysis. BMI had a significant effect on risk adjusted 1-year overall complications, 1-year revision surgery and 90-day surgical complications. The adjusted odd ratios increased significantly with BMI category. Especially morbidly obese patients with a BMI >40 kg/m. 2. had a threefold higher risk for deep infection and a two-fold higher risk for the overall complication and revision rates as compared to patients with a BMI <30 kg/m. 2. . Obesity plays an important role in patients undergoing primary THA, especially patients with a BMI beyond 40 kg/m. 2. have a markedly higher risk for revision surgery and overall complication rates. This study aims to increase awareness among physicians in order to improve risk stratifications and to better educate patients with regard to obesity and postoperative expectations prior to undergoing elective total hip arthroplasty

Aims

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

The February 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

The December 2022 Shoulder & Elbow Roundup³⁶⁰ looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae.

Aims

Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty.

Aims

To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality.

Background. Inpatient dislocation after total hip arthroplasty (THA) is considered a non-reimbursable “never event” by the Centers for Medicare and Medicaid Services. There is extensive evidence that technical procedural factors affect dislocation risk, but less is known about the influence of non-technical factors. We evaluated inpatient dislocation trends following elective primary THA, and identified patient and hospital characteristics associated with the occurrence of dislocation. Methods. We used discharge records from the Nationwide Inpatient Sample (2002–2011). Temporal trends were assessed and multivariable logistic regression modeling was used to identify factors associated with dislocation. Results. The in-hospital dislocation rate increased from 0.025% in 2002 to 0.15% in 2011, despite a downward trend in length of stay (P<0.001). Patient characteristics associated with the occurrence of dislocation were black or Hispanic race/ethnicity, lower household income, and Medicaid insurance. Comorbidities associated with dislocation included hemiparesis/hemiplegia, drug use disorder, chronic renal failure, psychosis, and obesity. Dislocations were less likely to occur at teaching hospitals and in the South. Conclusion. The in-hospital dislocation rate following elective primary THA is increasing, in spite of shorter stays and surgical advances over time. Given the sociodemographic disparities in dislocation risk documented herein, interventions to address social determinants of health might do as much or more to reduce the occurrence of dislocation than technical improvements