Aims. The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR). Methods. We performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale. Results. We enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001). Conclusion. Functional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected. Cite this article: Bone Jt Open 2023;4(1):46–52

Background. Masses are not uncommon in the foot and ankle. Most of these masses are benign, often leading clinicians to underestimate their potential for malignancy. Methods. We conducted a retrospective review of our clinical records, on patients with histologically confirmed musculoskeletal tumours of the foot and ankle, treated in a single nstitution between 2010 and 2019. The maximum diameter of each lesion was determined through MRI or Ultrasound analysis in centimeters. To develop a scoring system we compared the risk of malignancy with five criteria: site (proximal or distal to the first TMTJ), gender, age, composition and the diameter as observed. Results. Our study included 496 patients, of whom 39 (7.9%) were identified as having malignancies. The incidence of malignancy demonstrated an increased propensity among male patients, patients over 50 years of age and lesions located proximal to the TMTJ. A ROC Analysis determined that lesions measuring over 2.85 cm had an increased risk of malignancy, with a PPV of 31.1%, a NPV of 94.2%, a Sensitivity of 0.82, and a Specificity of 0.62. These identified patterns of risk were employed to formulate a scoring system, aimed at facilitating informed clinical judgment in the referral of patients to regional tumor services. Conclusion. The new OxFAT scoring system highlights the importance of lesion size, site, age and gender of the patient in determining the risk of malignancy in lump in the foot and ankle. We propose this new scoring system to aid health care professionals in managing these patients. Based on our results any patient with a foot or ankle mass of less than 2.85cm, an OxFAT score < 4/7 and no malignant or sinister features on MRI or USS can be managed locally with excision biopsy. All other patients should be referred urgently to a Regional Tumour Service

Aims. The metabolic equivalent of task (MET) score examines patient performance in relation to energy expenditure before and after knee arthroplasty. This study assesses its use in a knee arthroplasty population in comparison with the widely used Oxford Knee Score (OKS) and EuroQol five-dimension index (EQ-5D), which are reported to be limited by ceiling effects. Methods. A total of 116 patients with OKS, EQ-5D, and MET scores before, and at least six months following, unilateral primary knee arthroplasty were identified from a database. Procedures were performed by a single surgeon between 2014 and 2019 consecutively. Scores were analyzed for normality, skewness, kurtosis, and the presence of ceiling/floor effects. Concurrent validity between the MET score, OKS, and EQ-5D was assessed using Spearman’s rank. Results. Postoperatively the OKS and EQ-5D demonstrated negative skews in distribution, with high kurtosis at six months and one year. The OKS demonstrated a ceiling effect at one year (15.7%) postoperatively. The EQ-5D demonstrated a ceiling effect at six months (30.2%) and one year (39.8%) postoperatively. The MET score did not demonstrate a skewed distribution or ceiling effect either at six months or one year postoperatively. Weak-moderate correlations were noted between the MET score and conventional scores at six months and one year postoperatively. Conclusion. In contrast to the OKS and EQ-5D, the MET score was normally distributed postoperatively with no ceiling effect. It is worth consideration as an arthroplasty outcome measure, particularly for patients with high expectations. Cite this article: Bone Jt Open 2023;4(3):129–137

Abstract. Patient Reported Outcome Measures (PROMs) can be completed using paper and postal services (pPROMS) or via computer, tablet or smartphone (ePROMs). We have investigated whether there are differences in scores depending on the method of PROMs acquisition for the Oxford Knee (OKS) and the EQ-5D scores, at one and two years post operatively. Patient demographics, mode of preferred data collection and pre-and post-operative PROMs for Total Knee Replacements (TKRs) performed between 1st January 2018 and 31st December 2018 were collected. During the study period, 1573 patients underwent TKRs. The average OHS and EQ-5D pre-operatively scores was 19.47 and 0.40 respectively. 71.46% opted to undertake post-operative questionnaires using ePROMs. The remaining 28.54% opted for pPROMS. The one and two-year OHS for ePROMS patients increased to 37.64 and 39.76 while the OHS scores for pPROMS patients were 35.71 and 36.83. At the one and two-year post-operative time intervals, a Mann-Whitney test showed statistical significance between the modes of administration for OHS (P-Value = 0.044 and 0.01 respectively). The one and two-year EQ-5D for ePROMS patients increased to 0.76 and 0.78 while the EQ-5D scores for pPROMS patients were 0.73 and 0.76. The P-Value for Mann-Whitney tests comparing the modes of administration for EQ-5D were 0.04 and 0.07 respectively. There is no agreed mode of PROMs data acquisition for the OKS and EQ-5D Scores. While we have demonstrated an apparent difference in scores depending on the mode of administration, further work is required to establish the influence of potentially confounding factors

Disease specific or generic Patient Reported Outcome Measures (PROMs) can be completed by patients using paper and postal services (pPROMS) or via computer, tablet or smartphone (ePROMs) or by hybrid data collection, which uses both paper and electronic questionnaires. We have investigated whether there are differences in scores depending on the method of PROMs acquisition for the Oxford Hip Score (OHS) and the EQ-5D scores, at one and two years post operatively. Patients for this study were identified retrospectively from a prospectively compiled arthroplasty database held at the study centre. Patient demographics, mode of preferred data collection and pre- and post-operative PROMs for Total Hip Replacements (THRs) performed at this centre between 1. st. January 2018 and 31. st. December 2018 were collected. During the study period, 1494 patients underwent THRs and had complete one and two-year PROMs data available for analysis. All pre-operative scores were obtained by pPROMS. The average OHS and EQ-5D pre-operatively scores were 19.51 and 0.36 respectively. 72.02% of the patients consented to undertake post-operative questionnaires using ePROMs. The remaining 27.98% opted for pPROMS. The one and two-year OHS for ePROMS patients increased to 41.31 and 42.14 while the OHS scores for pPROMS patients were 39.80 and 39.83. At the one and two-year post-operative time intervals, a Mann-Whitney test showed statistical significance between the modes of administration for OHS (P-Value =0.044 and 0.01 respectively). The one and two-year EQ-5D for ePROMS patients increased to 0.83 and 0.84 while the EQ-5D scores for pPROMS patients were 0.79 and 0.81. The P-Value for Mann-Whitney tests comparing the modes of administration for EQ-5D were 0.13 and 0.07 respectively. Within Orthopaedics, PROMs have become the most widely used instrument to assess patients’ subjective outcomes. However, there is no agreed mode of PROMs data acquisition. While we have demonstrated an apparent difference in scores depending on the mode of administration, further work is required to establish the influence of potentially confounding factors such as patient age, gender and familiarity with computer technology

Aims. The primary aim of this study was to assess whether the postoperative Oxford Knee Score (OKS) demonstrated a ceiling effect at one and/or two years after total knee arthroplasty (TKA). The secondary aim was to identify preoperative independent predictors for patients that achieved a ceiling score after TKA. Methods. A retrospective cohort of 5,857 patients undergoing a primary TKA were identified from an established arthroplasty database. Patient demographics, body mass index (BMI), OKS, and EuroQoL five-dimension (EQ-5D) general health scores were collected preoperatively and at one and two years postoperatively. Logistic regression analysis was used to identify independent preoperative predictors of patients achieving postoperative ceiling scores. Receiver operating characteristic curve was used to identify a preoperative OKS that predicted a postoperative ceiling score. Results. The ceiling effect was 4.6% (n = 272) at one year which increased significantly (odds ratio (OR) 40.3, 95% confidence interval (CI) 30.4 to 53.3; p < 0.001) to 6.2% (n = 363) at two years, when defined as those with a maximal score of 48 points. However, when the ceiling effect was defined as an OKS of 44 points or more, this increased to 26.3% (n = 1,540) at one year and further to 29.8% (n = 1,748) at two years (OR 21.6, 95% CI 18.7 to 25.1; p < 0.001). A preoperative OKS of 23 or more and 22 or more were predictive of achieving a postoperative ceiling OKS at one and two years when defined as a maximal score or a score of 44 or more, respectively. Conclusion. The postoperative OKS demonstrated a small ceiling effect when defined by a maximal score, but when defined by a postoperative OKS of 44 or more the ceiling effect was moderate and failed to meet standards. The preoperative OKS was an independent predictor of achieving a ceiling score. Cite this article: Bone Joint J 2020;102-B(11):1519–1526

Aims. This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures. Methods. From our electronic database of 751 hip arthroplasty procedures, 221 patients were included. Patients were excluded if they had revision surgery, an alternative hip procedure, or incomplete data either preoperatively or at one-year follow-up. Included patients had a mean age of 59.4 years (SD 11.3) and 54.3% were male, incorporating 117 primary total hip and 104 hip resurfacing arthroplasty operations. Oxford Hip Score (OHS), EuroQol five-dimension questionnaire (EQ-5D), and the MET were recorded preoperatively and at one-year follow-up. The distribution was examined reporting the presence of ceiling and floor effects. Validity was assessed correlating the MET with the other scores using Spearman’s rank correlation coefficient and determining responsiveness. A subgroup of 93 patients scoring 48/48 on the OHS were analyzed by age, sex, BMI, and preoperative MET using the other metrics to determine if differences could be established despite scoring identically on the OHS. Results. Postoperatively the OHS and EQ-5D demonstrate considerable negatively skewed distributions with ceiling effects of 41.6% and 53.8%, respectively. The MET was normally distributed postoperatively with no relevant ceiling effect. Weak-to-moderate significant correlations were found between the MET and the other two metrics. In the 48/48 subgroup, no differences were found comparing groups with the EQ-5D, however significantly higher mean MET scores were demonstrated for patients aged < 60 years (12.7 (SD 4.7) vs 10.6 (SD 2.4), p = 0.008), male patients (12.5 (SD 4.5) vs 10.8 (SD 2.8), p = 0.024), and those with preoperative MET scores > 6 (12.6 (SD 4.2) vs 11.0 (SD 3.3), p = 0.040). Conclusion. The MET is normally distributed in patients following hip arthroplasty, recording levels of activity which are undetectable using the OHS. Cite this article: Bone Joint Res 2022;11(5):317–326

Introduction. Patient reported outcome measures (PROMs) are recognized as crucial in evaluating the outcome of total knee arthroplasty (TKA). New Knee Society Score (NKSS), introduced in 2011, is reported to be an effective, such outcome measure. Forgotten Joint score (FJS), introduced in 2012, has been validated but has only a few studies in literature reporting upon it. In a normal population without arthritis, the FJS is reported to be between 50–95, a higher score representing better status. Our aim was to determine 1) the FJS at 1-year post TKA, distributing patients in 2 groups of FJS less than/more than 50; assessing its ceiling and floor effect 2) the influence of age, sex, BMI, diabetes, thyroid, type of deformity, pre/post-operative flexion and 3) to compare and correlate FJS with NKSS and its sub-scores - Objective knee score(OKS) and Subjective knee score(SKS). Methods. We enrolled 181 patients (222 knees), who had primary TKA performed by the same surgeon at Lilavati Hospital & Research Centre, Mumbai, between June 2016 to February 2017. NKSS was administered to each patient preoperatively. At 1 year, they were prospectively called for review and NKSS and FJS were administered. 151 patients attended the review clinic and 17 patients completed the forms with the help of their physiotherapist and sent them via email. 13 patients who could not do either, were excluded from the study. Thus, we had 168 patients (207 knees) whose complete data was analyzed. Of 168 patients, 37 were males and 131 were females, with an average age of 67 years (37–85). Patients were divided into two groups based on their FJS score - Group A (FJS<50) and Group B (FJS≥50). The demographics and NKSS in both groups were compared. The study was approved by our Institutional Review Board. Statistical analysis was done using SPSS software. Raw data statistics for FJS was determined and unpaired t-test used to compare all parameters in Groups A and B. Correlation of NKSS to FJS was analyzed using Pearson's correlation test. Results. 1). FJS at 1 year: The median FJS at 1 year was 68.8 (IQR 41.7, mean 68, SD 25.3, range 0–100). It exhibited a 14% ceiling and 0.5% floor effect. There were 49 (24%) TKAs in Group A and 158 (76%) TKAs in Group B. 2). Comparison of parameters of age, sex, BMI, diabetes, thyroid disorder, type and severity of deformity and pre/post-operative flexion between the two groups showed no difference (unpaired t-test p>0.05) for each parameter, with the numbers available. 3).  . In Group A, the median values of NKSS, OKS and SKS were 174, 94 and 87 respectively as compared to the corresponding median values of 198, 98 and 100 in Group B. The difference in their corresponding values was seen to be significant (p<0.005). For both groups, the change in scores from preoperative to postoperative values was significant for NKSS (median of 73 vs 69, p=0.003) & SKS (median of 39 vs 30, p=0.006) but not for OKS (median of 47 vs 46, p=0.655). Correlation of the FJS to NKSS at 1 year was seen to be significant (p<0.005), the strength of correlation was found to be moderate (r=0.43). Each sub-score also showed significant correlation (p<0.005), which was weak to moderate (r=0.32 to 0.43). Conclusion. Mean FJS at 1-year post TKA was 68 which compares well with a mean of 72 reported in the normal population without arthritis. It exhibited 14% ceiling and 0.5% floor effects. FJS was not influenced by age, sex, BMI, co-morbidities, type/extent of deformity or pre/post-operative flexion range. Patients with higher FJS also had higher NKSS and higher OKS/SKS values but change in scores was significant only for NKSS & SKS. We observed a moderately positive correlation of FJS with NKSS at 1 year

Aims. The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales. Methods. We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents’ full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson’s correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments’ minimal clinically important difference (MCID). Results. The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson’s correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient’s CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire. Conclusion. Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy. Cite this article: Bone Jt Open 2022;3(10):786–794

Background. The Fracture Fixation Assessment Tool score (FFATs) was developed as an objective evaluation of post-operative fracture fixation radiographs as a means of appraisal and education. The tool has proven validity, simple to use and based upon AO principles of fracture fixation. This study has been designed to assess how FFATs changes throughout the training program in the UK. Methods. The local trauma database of a district general hospital, with trauma unit status was used to identify cases. Although FFATs is designed to apply to any fracture fixation, Weber B ankle fractures were selected as common injuries, which constitute indicative cases in T&O training. Grade of the primary surgeon and supervision level were both stratified. The initial and intraoperative radiographs were anonymised and presented to the assessor who had been blinded to the identity and grade of the surgeon, for scoring using FFATs. Results. 293 fractures around the ankle were identified from the Database between 2013 and 2016. After applying the inclusion criteria of Weber B fractures operatively fixed, Specialist training registrars and consultants, there were 99 cases for evaluation. These were grouped by training experience into 4 groups. (ST3-4, ST5-6, ST7-8, Consultants) and demonstrated a trend of increasing scores with experience level with a dip in consultant scores, albeit not statistically significant due to low numbers of cases at higher training grades. Conclusions. We present our first experience of using FFATs in a uniform series of fractures in surgeons of different training grades. There is a trend to increasing scores throughout training with a dip in consultant scores likely reflecting increased complexity of cases. Implications. FFATs could prove to be an invaluable appraisal tool for teaching and mentoring surgeons in training both locally in the United Kingdom and remotely overseas

This study aims to correlate Oxford shoulder score (OSS) to EQ5D score in healthy patients presenting to a shoulder clinic with shoulder pain. OSS and EQ5D scores were collected prospectively from 101 consecutive patients presenting with shoulder pain in a shoulder clinic at one specialist centre. Patients with ASA > 2 and other significant joint arthritis were excluded from the study. Scores were collected from electronic patient records. Spearman's rho correlation of oxford shoulder scores and EQ5D scores was completed. Mean age of subjects was 51.8 (range 19.1–81.9) years, 55 of 101 subjects were men (54%). Median OSS was 26 (range 3–48) and median EQ5D score was 0.76 (range 0–0.76). Correlation for all patients was 0.624 (Sig p<0.001). This study demonstrates a strong correlation between Oxford shoulder scoring and EQ5D in a fit and well shoulder surgery clinic population. It is possible that Oxford shoulder scores may be a useful indicator of quality of life in healthy shoulder clinic patients presenting with shoulder pain

Introduction. Patient satisfaction after total hip arthroplasty (THA) has been reported to be significantly better than after total knee arthroplasty (TKA). The same has been observed for the capacity to forget during daily life activities about the operated joint. Recently a new patient reported outcome score, the Forgotten Joint Score (FJS-12) a twelve item questionaire, has been used to evaluate postoperative outcome in joint arthroplasty. A better FJS-12 score was measured in THA than in TKA objectivating the intuitive feeling that the joint was more forgotten in THA than in TKA. Hypothesis. A higher preoperative FJS-12 score is the reason for a higher postoperative FJS-12 score in THA compared to TKA. Materials and methods. FJS-12 scores were prospectively collected in 75 THA and 75 TKA preoperatively and one year postoperative. Patients were stratified according to age and BMI. Effect size of treatment was calculated using the FJS-12. Results. No preoperative difference in mean (SD) FJS-12 was observed for THA (24(17) versus TKA (22(15)). The mean (SD) postoperative FJS-12 was significantly higher for THA (79(25)) than for TKA (73(22)). Effect size of treatment was 3.4 for TKA and 3.2 for THA. Mean (SD) for men in THA (89(25)) was significantly higher than for men in TKA (74(22)). Discussion. Postoperative differences in forgotten joint feeling after THA compared to TKA can not be explained by a preoperative difference. TKA is an effective surgery as measured by the effect size of treatment. Male TKA patients have worst outcome than male THA patients. This can probably be explained by mechanical or proprioceptive differences in between both types of arthroplasty

Aims. The main objective of this study was to examine whether the Oxford Shoulder Score (OSS) demonstrated floor or ceiling effects when used to measure outcomes following shoulder arthroplasty in a large national cohort. Secondary objectives were to assess its pain and function subscales, and to identify independent predictors for patients achieving a postoperative ceiling score following shoulder arthroplasty. Methods. Secondary database analysis of the National Joint Registry (NJR), which included 48,270 patients undergoing shoulder arthroplasty, was conducted. The primary outcome measure was the OSS. Secondary outcome measures were the OSS-Function Component Subscale and OSS-Pain Component Subscale. Floor and ceiling effects were considered to be present if > 15% of patients scored either the lowest or highest possible score. Logistic regression analysis was used to identify independent predictors for scoring the highest possible OSS score postoperatively. Results. Preoperatively, 1% of patients achieved the lowest possible OSS score (0) and 0.4% of patients achieved the highest possible score (48). Postoperatively, < 1% of patients achieved the lowest score at all timepoints, but the percentage achieving the highest score at six months was 8.3%, at three years 16.9%, and at five years 17%. Male patients, those aged between 60 and 89 years, and those undergoing an anatomical total shoulder arthroplasty (ATSA) were more likely to contribute to the ceiling effect seen in the OSS questionnaire. Pain and function subscales exhibited greater ceiling effects at three years and five years when compared with the overall OSS questionnaire. Logistic regression analysis showed that sex, procedure type, and preoperative OSS score were independent predictors for scoring the highest possible OSS at years. Conclusion. Based on NJR patient-reported outcome measures data, the OSS does not exhibit a ceiling effect at six months, but does at three years and five years, in part due to outcome scores of ATSA. Preoperative OSS, age, male sex, and ATSA are independent predictors of achieving a ceiling score. Cite this article: Bone Joint J 2021;103-B(11):1717–1724

Aims. The Uppföljningsprogram för cerebral pares (CPUP) Hip Score distinguishes between children with cerebral palsy (CP) at different levels of risk for displacement of the hip. The score was constructed using data from Swedish children with CP, but has not been confirmed in any other population. The aim of this study was to determine the calibration and discriminatory accuracy of this score in children with CP in Scotland. Methods. This was a total population-based study of children registered with the Cerebral Palsy Integrated Pathway Scotland. Displacement of the hip was defined as a migration percentage (MP) of > 40%. Inclusion criteria were children in Gross Motor Function Classification System (GMFCS) levels III to V. The calibration slope was estimated and Kaplan-Meier curves produced for five strata of CPUP scores to compare the observed with the predicted risk of displacement of the hip at five years. For discriminatory accuracy, the time-dependent area under the receiver operating characteristic curve (AUC) was estimated. In order to analyze differences in the performance of the score between cohorts, score weights, and subsequently the AUC, were re-estimated using the variables of the original score: the child’s age at the first examination, GMFCS level, head shaft angle, and MP of the worst hip in a logistic regression with imputation of outcomes for those with incomplete follow-up. Results. The discriminatory accuracy of the score in the new population of 367 children was high (AUC 0.78 (95% confidence interval (CI) 0.71 to 0.86)). The calibration of the score was insufficient (slope 0.48 (95% CI 0.31 to 0.65)), and the absolute risks of displacement of the hip in this population were overestimated. The AUC increased with re-estimated weights (0.85 (95% CI 0.79 to 0.91)). Conclusion. The CPUP Hip Score had a high ability to discriminate between children at different levels of risk for displacement of the hip. The score overestimated the absolute risks of displacement in this population, which may have resulted from differences in the way children were initially registered in the two programmes. The results are promising, but the score weights may need re-estimation before its clinical application in Scotland. Cite this article: Bone Joint J 2022;104-B(5):640–644

Aims. The Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient’s satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA. Methods. We retrospectively reviewed all patients who underwent primary elective THA from 2019 to 2020, and answered both the FJS-12 and the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) questionnaires one-year postoperatively. HOOS, JR score was used as the anchor to estimate the PASS of FJS-12. Two statistical methods were employed: the receiver operating characteristic (ROC) curve point, which maximized the Youden index; and 75th percentile of the cumulative percentage curve of patients who had the HOOS, JR score difference larger than the cut-off value. Results. This study included 780 patients. The mean one-year FJS-12 score was 65.42 (SD 28.59). The mean one-year HOOS, JR score was 82.70 (SD 16.57). A high positive correlation between FJS-12 and HOOS, JR was found (r = 0.74; p<0.001), making the HOOS, JR a valid external anchor. The threshold score of the FJS-12 that maximized the sensitivity and specificity for detecting a PASS was 66.68 (area under the curve = 0.8). The cut-off score value computed with the 75th percentile approach was 92.20. Conclusion. The PASS threshold for the FJS-12 at one year following primary THA was 66.68 and 92.20 using the ROC curve and 75th percentile approaches, respectively. These values can be used to achieve consensus about meaningful postoperative improvement to maximize the utility of the FJS-12 to evaluate and counsel patients undergoing THA. Cite this article: Bone Jt Open 2022;3(4):307–313

We compared the ceiling effects of two patient-rating scores, the Disability of the Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE), and a physician-rating score, the Modified Mayo Wrist Score (MMWS) in assessing the outcome of surgical treatment of an unstable distal radial fracture. A total of 77 women with a mean age of 64.2 years (50 to 88) who underwent fixation using a volar locking plate for an unstable distal radial fracture between 2011 and 2013 were enrolled in this study. All completed the DASH and PRWE questionnaires one year post-operatively and were assessed using the MMWS by the senior author. The ceiling effects in the outcome data assessed for each score were estimated. The data assessed with both patient-rating scores, the DASH and PRWE, showed substantial ceiling effects, whereas the data assessed with MMWS showed no ceiling effect. Researchers should be aware of a possible ceiling effect in the assessment of the outcome of the surgical treatment of distal radial fractures using patient-rating scores. It could also increase the likelihood of a type II error. Cite this article: Bone Joint J 2015;97-B:1651–6

There is no consensus on how to evaluate and grade pin site infection. A precise, objective and reliable pin site infectious score is warranted. The literature was reviewed for pin site infection classification systems, The Modified Gordon Score (MGS) grade 0-6 was used. The aim was to test the reliability of The Modified Gordon Infection Score. The observed agreement and inter-rater reliability were investigated between nurse and doctors. MGS was performed in the outpatient clinic at Aalborg University Hospital, Denmark on 1472 pin sites in 119 patients by one nurse and one of three orthopaedic surgeons blinded to each other's judgement. The data was stored in a Red Cap Database for further statistical analysis. The observed agreement between the nurse and the 3 orthopaedic surgeons was evaluated with a one-way random-effect model with interclass correlation with absolute agreement. Furthermore the observed agreement for each of the 3 surgeons with the nurse was calculated. The distribution of MGS infection grade in the 1472 pin sites was: Grade 0; n=1372, Grade 1; n=32, Grade 2; n=39, Grade 3; n=24, Grade 4; n=5, Grade 5; n=0, Grade 6; n=0. The observed agreement between the nurse and the surgeons was calculated as 98%. The ICC estimated between nurse and the surgeons was 0,8943 (ICC >0,85 = reliable). The grading was done by three different doctors with an agreement with the nurse as follows. Rater1 (n=416) =99,5 %, Rater2 (n=1440) =97,4%, Rater3 (n=1440) =96,6%. A limitation to this study is that the dataset represents mostly clean pin sites with MGS 0. Only 100 pin sites had signs of superficial infection MGS 1-4 none above 4. We found that the MGS infection score is highly reliable for low grade infections but we cannot conclude on reliability in severe infections

Objective: The purpose of this study was to determine how changes in functional shoulder score (Constant Score) affected the values of the SF-36 score, to determine the amount of functional score change to be considered relevant. Material and Method: 427 patients were included. All of them were assessed with a functional shoulder score (Constant Score) and fulfilled SF-36 score. Mean age was of 50,61(18–85), 200 of them were male and 227 female. 280 were considered to be active while 147 were retired as far as working status is concerned. There were 191 patients with university studies and 236 with primary studies. Primary diagnosis was cuff disorders in 265 patients, old-fracture in 43, degenerative in 72 and instability in 34. Correlations were performed with Spearman’s rho and regression models were evaluated. Results: There was a moderate but significant correlation between the total Constant Score and PF_NORM (0,511) and US standardized physical component (US STPH) (0,491) of the SF-36. For every point of increase in the Constant score the SF-36 increases 0,235 points. Looking into the different items of the Constant Score, Activities of daily living (ADL) and strength presented the stronger correlation with SF-36 (0,428, 0,411). In the regression model, every point of increase of pain, ADL, forward elevation, external rotation and internal rotation means an increase of 0,472, 0,39, 0,84, 0,82 and 0,86 of the US STPH of the SF-36. Conclusions: Whenever the outcome of any shoulder treatment is analyzed it has to be taken into account that for every point of increase of the Total Constant Score just 0,235 points of the US SPTH of the SF-36 increase. Depending on the mean value of the US SPTH of the SF-36 of the population studied, the relevant increase of Constant Score can be calculated. Mobility improvements seem to have more influence that pain changes as far as increasing the US SPTH of the SF-36 is concerned

To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU). Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers. In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs 7, p<0.001). A ROC curve demonstrated that a RUSU ≤8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥9 (n = 2/33; OR 49.6, 95% CI 8.6–284.7). Based on a PPV of 76%, if all patients with a RUSU ≤8 underwent fixation at 6-weeks, the number of procedures needed to avoid one nonunion would be 1.3. The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures

Introduction and Aims: The clinical studies of knee disorders utilise patients’ activity levels to measure issues that are really important to the patients. Knowing the large variations among patients in terms of the frequency and intensity of sports participation and frustrated by the lack of relevance and specificity of current questionnaires to the Australian public, the authors have devised their own. Method: The new questionnaire was sent to all members of the Australian Knee Society in an attempt to formulate a consensus view that could then be sent for reliablility and validity testing. The score is represented by two numbers. The first one represents the activity performed and the second, the level at which it was played. These scores are multiplied to give a variable score ranging from one to 20. Results: An 80% response rate was achieved. Of those that responded, 30.5% agreed completely with the questionnaire as it stood, 69.5% agreed with few modifications, and none disagreed. Conclusion: A rating of activity level is critical for studies comparing two treatments to ensure that the patient groups are equivalent. We believe that the new Wood-ford activity level scale is fast, easy to use and will facilitate a more accurate comparision among patients with knee injuries in sports medicine. It is easily transferred between different countries and their common sports

Patient reported outcome measures (PROMs) after total knee arthroplasty (TKA) are typically used to assess longitudinal change in pain and function after total knee arthroplasty (TKA). The Patient's Knee Implant Performance (PKIP) score was developed to evaluate outcomes more broadly including function, stability, confidence, and satisfaction. Although validated in patients having a primary TKA, the PKIP has not been evaluated as an outcome measure for patients having revision TKA. This study examined patient outcomes at one year following primary and revision TKA measured using the PKIP, compared to Oxford Knee Scores. A retrospective analysis of pre-operative and one-year post-operative outcomes was completed for 39 patients (21 female) who had primary (n=27) or revision (n=12) TKA with a single surgeon between 2017 and 2020. The mean age was 69.2±7.4 years, and mean weight 87.4± 5.1kg. The change over time and correlation between the self-reported outcome measures was evaluated. There was a significant improvement in the PKIP overall score at the 12-month follow-up (32± 13 v 69± 15, p= <0.001), with no significant difference between groups (3.3 points, p=0.50). Among the PKIP sub-scores, there was a significant improvement in knee confidence (3.5±2 vs 7.7±2; p<0.001), stability (3.4±2 vs 7.4±3; p<0.001) and satisfaction (2.5±1.7 vs 6.6±3, p<0.001). Between group differences in PKIP sub-scores one year after surgery were small and non-significant. For all patients, the OKS and PKIP scores were moderately correlated before surgery (r=0.64, p=<0.05), and at 1 year after surgery (r=0.61, p= <0.001). Significant improvements in knee confidence, stability, and satisfaction one year after TKA were identified from the PKIP responses, with no significant difference between primary and revision surgery. The moderate correlation with the OKS suggests these questionnaires measure difference constructs and may provide complementary outcome information in this patient cohort

Utility score is a preference-based measure of general health state – where 0 is equal to death, and 1 is equal to perfect health. To understand a patient's smallest perceptible change in utility score, the minimal clinically important difference (MCID) can be calculated. However, there are multiple methods to calculate MCID with no consensus about which method is most appropriate. The aim of this study is to calculate MCID values for the Veterans-RAND 12 (VR12) utility score using varying methods. Our hypothesis is that different methods will yield different MCID values. A tertiary institutional registry (SMART) was used as the study cohort. Patients who underwent unilateral TKA for osteoarthritis from January 2012 to January 2020 were included. Utility score was calculated from VR12 responses using the standardised Brazier's method. Distribution and anchor methods were used for the MCID calculation. For distribution methods, 0.5 standard deviations of the baseline and change scores were used. For anchor methods, the physical and emotional anchor questions in the VR12 survey were used to benchmark utility score outcomes. Anchor methods included mean difference in change score, mean difference in 12 month score, and receiver operating characteristics (ROC) analysis with the Youden index. Complete case analysis of 1735 out of 1809 eligible patients was performed. Significant variation in the MCID estimates for VR12 utility score were reported dependent on the calculation method used. The MCID estimate from 0.5 standard deviations of the change score was 0.083. The MCID estimate from the ROC analysis method using physical or emotional anchor question improvement was 0.115 (CI95 0.08-0.14; AUC 0.656). Different MCID calculation methods yielded different MCID values. Our results suggest that MCID is not an umbrella concept but rather many distinct concepts. A general consensus is required to standardise how MCID is defined, calculated, and applied in clinical practice

The Nottingham Hip Fracture Score (NHFS) was developed in 2007 as a predictor of 30-day mortality after hip fracture surgery following a neck of femur fracture. The National Hip Fracture Database is the standard used which calculated their own score using national data. The NHF score for 30-day mortality was calculated for 50 patients presenting with a fractured neck femur injury between January 2020 to March 2020. A score <5 was classified as low risk and >/=5 as high risk. Aim was to assess the accuracy in calculating the Nottingham Hip Fracture Score against the National Hip Fracture Database. To explore whether it should it be routinely included during initial assessment to aid clinical management?. There was an increase in the number of mortalities observed in patients who belonged to the high-risk group (>=5) compared to the low risk group. COVID-19 positive patients had worse outcomes with average 30-day mortality of 6.78 compared to the average of 6.06. GEH NHF score per month showed significant accuracy against the NHFD scores. The identification of high-risk groups from their NHF score can allow for targeted optimisations and elucidation of risk factors easily gathered at the point of hospitalisation. The NHFS is a valuable tool and useful predictor to stratify the risk of 30-day mortality and 1-year mortality after hip fracture surgery. Inclusion of the score should be considered as mandatory Trust policy for neck of femur fracture patients to aid clinical management and improve patient safety overall

Abstract. Background. The Forgotten Joint Score (FJS) is a 12-item patient reported outcome measurement instrument. It was developed with classical test theory, without testing assumptions such as unidimensionality (all items reflect one underlying factor), appropriate weighting of each item, no differential item function (DIF, different groups answer the same way), and monotonicity (people with higher function have higher score). We applied item response theory (IRT) to improve the validity of FJS to contemporary standards to optimise it for ongoing use. Research Questions. Does the FJS reflect one latent trait? Can an IRT model be fitted to the FJS to provide interval-scaled measurement?. Methodology. Participants undergoing primary total knee replacement provided pre-operative and post-operative (6-months) responses for FJS. An exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and Mokken analysis were conducted. The data were fitted to a graded response model (GRM). Results. 1288 response patterns were analysed. EFA showed a one factor model (all 12 items load to one underlying trait). CFA demonstrated excellent model fit (X2 <0.001, Tucker Lewis Index=0.96, Comparative Fit Index=0.96). Items did not have equal weighting. The FJS demonstrated good monotonicity with no differential item functioning by sex, age, or body mass index. Conclusions. The FJS meets key validity assumptions supporting its use in clinical practice and research. The IRT-adapted FJS provides continuous measurements with greater granularity including individual measurement error. This adapted score has advantages over traditional FJS scoring, being interval scaled (using GRM) and can be retrospectively applied to existing response sets

The widely used Fracture Risk Assessment Tool (FRAX) estimates a 10-year probability of major osteoporotic fracture (MOF) using age, sex, body mass index, and seven clinical risk factors, including prior history of fracture. Prior fracture is a binary variable in FRAX, although it is now clear that prior fractures affect future MOF risk differently depending on their recency and site. Risk of MOF is highest in the first two years following a fracture and then progressively decreases with time – this is defined as imminent risk. Therefore, the FRAX tool may underestimate true fracture risk and result in missed opportunities for earlier osteoporosis management in individuals with recent MOF. To address this, multipliers based on age, sex, and fracture type may be applied to baseline FRAX scores for patients with recent fractures, producing a more accurate prediction of both short- and long-term fracture risk. Adjusted FRAX estimates may enable earlier pharmacologic treatment and other risk reduction strategies. This study aimed to report the effect of multipliers on conventional FRAX scores in a clinical cohort of patients with recent non-hip fragility fractures. After obtaining Research Ethics Board approval, FRAX scores were calculated both before and after multiplier adjustment, for patients included in our outpatient Fracture Liaison Service who had experienced a non-hip fragility fracture between June 2020 and November 2021. Patients age 50 years or older, with recent (within 3 months) forearm (radius and/or ulna) or humerus fractures were included. Exclusion criteria consisted of patients under the age of 50 years or those with a hip fracture. Age- and sex-based FRAX multipliers for recent forearm and humerus fractures described by McCloskey et al. (2021) were used to adjust the conventional FRAX score. Low, intermediate and high-risk of MOF was defined as less than 10%, 10-20%, and greater than 20%, respectively. Data are reported as mean and standard deviation of the mean for continuous variables and as proportions for categorical variables. A total of 91 patients with an average age of 64 years (range = 50-97) were included. The majority of patients were female (91.0%), with 73.6% sustaining forearm fractures and 26.4% sustaining humerus fractures. In the forearm group, the average MOF risk pre- and post-multiplier was 16.0 and 18.8, respectively. Sixteen percent of patients (n = 11) in the forearm group moved from intermediate to high 10-year fracture risk after multiplier adjustment. Average FRAX scores before and after adjustment in the humerus group were 15.7 and 22.7, respectively, with 25% (n = 6) of patients moving from an intermediate risk to a high-risk score. This study demonstrates the clinically significant impact of multipliers on conventional FRAX scores in patients with recent non-hip fractures. Twenty-five percent of patients with humerus fractures and 16% of patients with forearm fractures moved from intermediate to high-risk of MOF after application of the multiplier. Consequently, patients who were previously ineligible for pharmacologic management, now met criteria. Multiplier-adjusted FRAX scores after a recent fracture may more accurately identify patients with imminent fracture risk, facilitating earlier risk reduction interventions

Background. Surgical intervention for hallux valgus and hallux rigidus is an option for patients presenting with severe pain and deformity. Literature suggest that patients with high Pain Catastrophisation Scores (PCS) have poorer outcomes in spinal and to a lesser extent in arthroplasty surgery. There is however very little evidence pertaining to foot and ankle surgery. Aim. We aimed to study whether catastrophisation as measured by PCS influenced the outcomes following surgery for Hallux valgus and rigidus. Methodology. Ethical approval for this prospective portfolio study was obtained from NRES Committee South Central and Oxford. Approval was granted from the local R&D department prior to data collection. All patients listed for surgery for hallux pathology to the four senior authors were invited to participate. Recruitment into the study started in September 2017 and is ongoing. Pain catastrophising score (PCS), Manchester Oxford Foot Questionnaire (Mox-FQ), Visual analog scale (VAS) for pain and EQ-5D-3L questionnaires were completed Pre-op (baseline), and at 3, 6 and 12- months post-surgery. Results. 93 patients with minimum follow-up of 6 months were analysed using SPSS software. A P-value of less than 0.05 was considered significant. The mean age of the patients was 58.5 years and 83% were women. 70% of the patients had surgery for hallux valgus and rest for rigidus. Both PROMS and PCS improved significantly following surgical intervention. Patients with higher pre-operative PCS had a worse 6-month PROM score and more pain. Conclusion. This study confirms that pre-operative catastrophisation as demonstrated by a high PCS score has an adverse effect on outcomes following hallux surgery. Risk stratifying patients based on their Pre-op PCS scores may be a useful strategy to identify those at risk of poorer outcomes. We recommend that behavioural change interventions should be considered to try to improve outcomes in patients with pre-op PCS

We assessed the effect of social deprivation upon the Oxford knee score (OKS), the Short-Form 12 (SF-12) and patient satisfaction after total knee replacement (TKR). An analysis of 966 patients undergoing primary TKR for symptomatic osteoarthritis (OA) was performed. Social deprivation was assessed using the Scottish Index of Multiple Deprivation. Those patients that were most deprived underwent surgery at an earlier age (p = 0.018), were more likely to be female (p = 0.046), to endure more comorbidities (p = 0.04) and to suffer worse pain and function according to the OKS (p < 0.001). In addition, deprivation was also associated with poor mental health (p = 0.002), which was assessed using the mental component (MCS) of the SF-12 score. Multivariable analysis was used to identify independent predictors of outcome at one year. Pre-operative OKS, SF-12 MCS, back pain, and four or more comorbidities were independent predictors of improvement in the OKS (all p < 0.001). Pre-operative OKS and improvement in the OKS were independent predictors of dissatisfaction (p = 0.003 and p < 0.001, respectively). Although improvement in the OKS and dissatisfaction after TKR were not significantly associated with social deprivation per se, factors more prevalent within the most deprived groups significantly diminished their improvement in OKS and increased their rate of dissatisfaction following TKR. Cite this article: Bone Joint J 2013;95-B:52–8

Aims. The preoperative grading of chondrosarcomas of bone that accurately predicts surgical management is difficult for surgeons, radiologists, and pathologists. There are often discrepancies in grade between the initial biopsy and the final histology. Recent advances in the use of imaging methods have shown promise in the ability to predict the final grade. The most important clinical distinction is between grade 1 chondrosarcomas, which are amenable to curettage, and resection-grade chondrosarcomas (grade 2 and 3) which require en bloc resection. The aim of this study was to evaluate the use of a Radiological Aggressiveness Score (RAS) to predict the grade of primary chondrosarcomas in long bones and thus to guide management. Methods. A total of 113 patients with a primary chondrosarcoma of a long bone presenting between January 2001 and December 2021 were identified on retrospective review of a single oncology centre’s prospectively collected database. The nine-parameter RAS included variables from radiographs and MRI scans. The best cut-off of parameters to predict the final grade of chondrosarcoma after resection was determined using a receiver operating characteristic curve (ROC), and this was correlated with the biopsy grade. Results. A RAS of ≥ four parameters was 97.9% sensitive and 90.5% specific in predicting resection-grade chondrosarcoma based on a ROC cut-off derived using the Youden index. Cronbach’s α of 0.897 was derived as the interclass correlation for scoring the lesions by four blinded reviewers who were surgeons. Concordance between resection-grade lesions predicted from the RAS and ROC cut-off with the final grade after resection was 96.46%. Concordance between the biopsy grade and the final grade was 63.8%. However, when the patients were analyzed based on surgical management, the initial biopsy was able to differentiate low-grade from resection-grade chondrosarcomas in 82.9% of biopsies. Conclusion. These findings suggest that the RAS is an accurate method for guiding the surgical management of patients with these tumours, particularly when the initial biopsy results are discordant with the clinical presentation. Cite this article: Bone Joint J 2023;105-B(7):808–814

Aims. The aim of this study was to identify the minimal clinically important difference (MCID), minimal important change (MIC), minimal detectable change (MDC), and patient-acceptable symptom state (PASS) in the Forgotten Joint Score (FJS) according to patient satisfaction six months following total hip arthroplasty (THA) in a UK population. Methods. During a one-year period, 461 patients underwent a primary THA and completed preoperative and six-month FJS, with a mean age of 67.2 years (22 to 93). At six months, patient satisfaction was recorded as very satisfied, satisfied, neutral, dissatisfied, or very dissatisfied. The difference between patients recording neutral (n = 31) and satisfied (n = 101) was used to define the MCID. MIC for a cohort was defined as the change in the FJS for those patients declaring their outcome as satisfied, whereas receiver operating characteristic curve analysis was used to determine the MIC for an individual and the PASS. Distribution-based methodology was used to calculate the MDC. Results. Using satisfaction as the anchor, the MCID for the FJS was 8.1 (95% confidence interval (CI) 3.7 to 15.9; p = 0.040), which was affirmed when adjusting for confounding. The MIC for the FJS for a cohort of patients was 17.7 (95% CI 13.7 to 21.7) and for an individual patient was 18. The MDC90 for the FJS was eight, meaning that 90% of patients scoring more than this will have experienced a real change that is beyond measurement error. The PASS threshold for the FJS was defined as 29. Conclusion. The MCID and MIC can be used respectively to assess whether there is a clinical difference between two groups, or whether a cohort or patient has had a meaningful change in their FJS. Both values were greater than measurement error (MDC90), suggesting a real change. The PASS threshold for the postoperative FJS can be used as a marker of achieving patient satisfaction following THA. Cite this article: Bone Joint J 2021;103-B(12):1759–1765

The purpose of this study is the evaluate the net promotor score of arthroscopic subacromial decompression and rotator cuff repair. The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from −100 to 100. Positive scores indicate good performance. This study quantifies the scores in 71 patients at 1 year following arthroscopic sub acromial decompression and rotator cuff repair. All of the procedures were performed by 1 consultant shoulder specialist. The patient filled out a shoulder questionnaire pre-operatively, at 6 months and 1 year. The score was 72 for subacromial decompression (n = 32) and 85 for rotator cuff repair +/− decompression (n = 39). Oxford shoulder score was also taken and had a rise of 4.3 and 6.9 respectively. Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction. We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction

Aims. The aims of this study were to assess mapping models to predict the three-level version of EuroQoL five-dimension utility index (EQ-5D-3L) from the Oxford Knee Score (OKS) and validate these before and after total knee arthroplasty (TKA). Methods. A retrospective cohort of 5,857 patients was used to create the prediction models, and a second cohort of 721 patients from a different centre was used to validate the models, all of whom underwent TKA. Patient characteristics, BMI, OKS, and EQ-5D-3L were collected preoperatively and one year postoperatively. Generalized linear regression was used to formulate the prediction models. Results. There were significant correlations between the OKS and EQ-5D-3L preoperatively (r = 0.68; p < 0.001) and postoperatively (r = 0.77; p < 0.001) and for the change in the scores (r = 0.61; p < 0.001). Three different models (preoperative, postoperative, and change) were created. There were no significant differences between the actual and predicted mean EQ-5D-3L utilities at any timepoint or for change in the scores (p > 0.090) in the validation cohort. There was a significant correlation between the actual and predicted EQ-5D-3L utilities preoperatively (r = 0.63; p < 0.001) and postoperatively (r = 0.77; p < 0.001) and for the change in the scores (r = 0.56; p < 0.001). Bland-Altman plots demonstrated that a lower utility was overestimated, and higher utility was underestimated. The individual predicted EQ-5D-3L that was within ± 0.05 and ± 0.010 (minimal clinically important difference (MCID)) of the actual EQ-5D-3L varied between 13% to 35% and 26% to 64%, respectively, according to timepoint assessed and change in the scores, but was not significantly different between the modelling and validation cohorts (p ≥ 0.148). Conclusion. The OKS can be used to estimate EQ-5D-3L. Predicted individual patient utility error beyond the MCID varied from one-third to two-thirds depending on timepoint assessed, but the mean for a cohort did not differ and could be employed for this purpose. Cite this article: Bone Jt Open 2022;3(7):573–581

Introduction: Scoring systems for assessment of shoulder function are invaluable tools in determining changes in a patient’s condition. We utilised two commonly used assessment tools in patients with conservatively treated proximal humeral fractures to establish their behaviour in this patient group. Methods: OSS and Constant Scores were collected prospectively at 3 and 12 months post injury, for 103 consecutive patients treated conservatively for proximal humeral fractures. Comparison of the scores was undertaken by creating scattergraphs, calculating Pearson’s correlation coefficient and producing Bland and Altman plots. Sensitivity to change was calculated using paired t-tests. Linear regression analysis was finally performed to predict Constant Score from the OSS. Results: 177 sets of scores were collected. The scores correlated well with a correlation coefficient (r) of 0.84 (p< 0.001,n=177). This relationship was equally strong at 3 (r=0.77 (p< 0.001,n=94)) and 12 months (r=0.87 (p< 0.001,n=83)) and demonstrated a clear relationship between the scoring systems. Bland and Altman plots showed good agreement between the scores. Both scores were sensitive to change over time (OSS (t(81)=6.14,p< 0.001), Constant (t(80)=−10.27,p< 0.001)). Regression analysis produced a regression equation (R2=0.70) of: Constant Score=99.3-(1.67 times OSS). This level of model fit was statistically significant (F(1,175)=412.8,(p< 0.001)). Conclusion: This study provides information about the behaviour of two frequently used functional scoring systems in patients with proximal humeral fractures. Based on our finding we feel that these scores are appropriate assessment tools in these patients. The OSS may also be considered as an alternative for assessing longer term follow up as, being solely subjective, it is easier to administer and correlates well with the Constant Score

Aims. The incidence of bone metastases is between 20% to 75% depending on the type of cancer. As treatment improves, the number of patients who need surgical intervention is increasing. Identifying patients with a shorter life expectancy would allow surgical intervention with more durable reconstructions to be targeted to those most likely to benefit. While previous scoring systems have focused on surgical and oncological factors, there is a need to consider comorbidities and the physiological state of the patient, as these will also affect outcome. The primary aim of this study was to create a scoring system to estimate survival time in patients with bony metastases and to determine which factors may adversely affect this. Methods. This was a retrospective study which included all patients who had presented for surgery with metastatic bone disease. The data collected included patient, surgical, and oncological variables. Univariable and multivariable analysis identified which factors were associated with a survival time of less than six months and less than one year. A model to predict survival based on these factors was developed using Cox regression. Results. A total of 164 patients were included with a median survival time of 1.6 years (interquartile range 0.5 to 3.1) after surgery. On multivariable analysis, a higher American Society of Anesthesiologists grade (p < 0.001), a high white cell count (p = 0.002), hyponatraemia (p = 0.001), a preoperative resting heart rate of > 100 bpm (p = 0.052), and the type of primary cancer (p = 0.026) remained significant predictors of reduced survival time. The predictive model developed showed good discrimination and calibration to predict both six- and 12-month survival in patients with metastatic bone disease. Conclusion. In addition to surgical and oncological factors, the level of comorbidity and physiological state of the patient has a significant impact on survival in patients with metastatic bone disease. These factors should be considered when assessing the appropriateness of surgical intervention. This is the first study to examine other patient factors alongside surgical and oncological data to identify a relationship between these and survival. Cite this article: Bone Joint J 2021;103-B(11):1725–1730

The purpose of this study was to develop a quality appraisal tool for the assessment of laboratory basic science biomechanical studies. Materials andScore development comprised of the following phases: item identification/development, item reduction, content/face/criterion validity, weighting, test-retest reliability and internal consistency. For item identification/development, the panel was asked to independently list criteria and factors they considered important for cadaver study and generate items that should be used to appraise cadaver study quality. For content validity, the content validity ratio (CVR) was calculated. The minimum accepted content validity index (CVI) was set to 0.85. For weighting, equal weight for each item was 6.7% [15 items]. Based on these figures the panel was asked to either upscale or downscale the weight for each item ensuring that the final sum for all items was 100%. Face validity was assessed by each panel member using a Likert scale from 1–7. Strong face validity was defined as a mean score of >5. Test-retest reliability was assessed using 10 randomly selected studies. Criterion validity was assessed using the QUACS scale as standard. Internal consistency was assessed using Cronbach's alpha. Five items reached a CVI of 1 and 10 items a CVI of 0.875. For weighting five items reached a final weight of 10% and ten items 5%. The mean score for face validity was 5.6. Test-retest reliability ranged from 0.78–1.00 with 9 items reaching a perfect score. Criterion validity was 0.76 and considered to be strong. Cronbach's alpha was calculated to be 0.71 indicating acceptable internal consistency. The new proposed quality score for basic science studies consists of 15 items and has been shown to be reliable, valid and of acceptable internal consistency. It is suggested that this score should be utilised when assessing basic science studies

Aims. The aim of this study was to perform a cross-cultural adaptation of Oxford Hip Score (OHS) to Indonesian, and to evaluate its psychometric properties. Methods. We performed a cross-cultural adaptation of Oxford Hip Score into Indonesian language (OHS-ID) and determined its internal consistency, test-retest reliability, measurement error, floor-ceiling effect, responsiveness, and construct validity by hypotheses testing of its correlation with Harris Hip Score (HHS), vsual analogue scale (VAS), and Short Form-36 (SF-36). Adults (> 17 years old) with chronic hip pain (osteoarthritis or osteonecrosis) were included. Results. A total of 125 patients were included, including 50 total hip arthroplasty (THA) patients with six months follow-up. The OHS questionnaire was translated into Indonesian and showed good internal consistency (Cronbach’s alpha = 0.89) and good reliability (intraclass correlation = 0.98). The standard error of measurement value of 2.11 resulted in minimal detectable change score of 5.8. Ten out of ten (100%) a priori hypotheses were met, confirming the construct validity. A strong correlation was found with two subscales of SF-36 (pain and physical function), HHS (0.94), and VAS (-0.83). OHS-ID also showed good responsiveness for post-THA series. Floor and ceiling effect was not found. Conclusion. The Indonesian version of OHS showed similar reliability and validity with the original OHS. This questionnaire will be suitable to assess chronic hip pain in Indonesian-speaking patients. Cite this article: Bone Jt Open 2021;2(9):765–772

Aims. The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD). Methods. In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L. Results. A total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity). Conclusion. OHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data. Cite this article: Bone Jt Open 2023;4(3):138–145

Aims. Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. Methods. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. Results. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. Conclusion. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations. Cite this article: Bone Joint J 2023;105-B(1):21–28

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. The modified Glasgow Prognostic Score (mGPS) uses preoperative CRP and albumin to calculate a score from 0 to 2 (2 being associated with poor outcomes). mGPS is validated in multiple carcinomas. To date, its use in soft-tissue sarcoma (STS) is limited, with only small cohorts reporting that increased mGPS scores correlates with decreased survival in STS patients. Methods. This retrospective multicentre cohort study identified 493 STS patients using clinical databases from six collaborating hospitals in three countries. Centres performed a retrospective data collection for patient demographics, preoperative blood results (CRP and albumin levels and neutrophil, leucocyte, and platelets counts), and oncological outcomes (disease-free survival, local, or metastatic recurrence) with a minimum of two years' follow-up. Results. We found that increased mGPS, tumour size, grade, neutrophil/lymphocyte ratio, and disease recurrence were associated with reduced survival. Importantly, mGPS was the best at stratifying prognosis and could be used in conjunction with tumour grade to sub-stratify patient survival. Conclusion. This study demonstrated that prognosis of localized STS strongly correlates with mGPS, as an increasing score is associated with a poorer outcome. We note that 203 patients (41%) with an STS have evidence of systemic inflammation. We recommend the mGPS and other biochemical blood indicators be introduced into the routine diagnostic assessment in STS patients to stratify patient prognosis. Its use will support clinical decision-making, especially when morbid treatment options such as amputation are being considered. Cite this article: Bone Joint J 2022;104-B(1):168–176

Aims. The aim of this study was to identify the minimal clinically important difference (MCID), minimal important change (MIC), minimal detectable change (MDC), and patient-acceptable symptom state (PASS) threshold in the Forgotten Joint Score (FJS) according to patient satisfaction six months following total knee arthroplasty (TKA). Methods. During a one-year period 484 patients underwent a primary TKA and completed preoperative and six-month FJS and OKS. At six months patients were asked, “How satisfied are you with your operated knee?” Their response was recorded as: very satisfied, satisfied, neutral, dissatisfied, or very dissatisfied. The difference between patients recording neutral (n = 44) and satisfied (n = 153) was used to define the MCID. MIC for a cohort was defined as the change in the FJS for those patients declaring their outcome as satisfied, whereas receiver operating characteristic curve analysis was used to determine the MIC for an individual and the PASS threshold. Distribution-based methodology was used to calculate the MDC. Results. Using satisfaction as the anchor question, the MCID for the FJS was 16.6 (95% confidence interval (CIs) 8.9 to 24.3; p < 0.001) and when adjusting for confounding this decreased to 13.7 points (95% CI 4.8 to 22.5; p < 0.001). The MIC for the FJS for a cohort of patients was 17.7 points and for an individual patient was 10 points. The MDC90 for the FGS was 12 points; where 90% of patients scoring more than this will have experienced a real change that is beyond measurement error. The PASS was defined as 22 points or more in the postoperative FJS. Conclusion. The estimates for MCID and MIC can be used to assess whether there is clinical difference between two groups and whether a cohort/patient has had a meaningful change in their FJS, respectively. The MDC90 of 12 points suggests a value lower than this may fall within measurement error. A postoperative FJS of 22 or more was predictive of achieving PASS. Cite this article: Bone Joint J 2021;103-B(5):846–854

The ability to calculate quality-adjusted life-years (QALYs) for degenerative cervical myelopathy (DCM) would enhance treatment decision making and facilitate economic analysis. QALYs are calculated using utilities, or health-related quality-of-life (HRQoL) weights. An instrument designed for cervical myelopathy disease would increase the sensitivity and specificity of HRQoL assessments. The objective of this study is to develop a multi-attribute utility function for the modified Japanese Orthopedic Association (mJOA) Score. We recruited a sample of 760 adults from a market research panel. Using an online discrete choice experiment (DCE), participants rated 8 choice sets based on mJOA health states. A multi-attribute utility function was estimated using a mixed multinomial-logit regression model (MIXL). The sample was partitioned into a training set used for model fitting and validation set used for model evaluation. The regression model demonstrated good predictive performance on the validation set with an AUC of 0.81 (95% CI: 0.80-0.82)). The regression model was used to develop a utility scoring rubric for the mJOA. Regression results revealed that participants did not regard all mJOA domains as equally important. The rank order of importance was (in decreasing order): lower extremity motor function, upper extremity motor function, sphincter function, upper extremity sensation. This study provides a simple technique for converting the mJOA score to utilities and quantify the importance of mJOA domains. The ability to evaluate QALYs for DCM will facilitate economic analysis and patient counseling. Clinicians should use these findings in order to offer treatments that maximize function in the attributes viewed most important by patients

Aims. The Patient-Reported Outcomes Measurement Information System (PROMIS) has demonstrated faster administration, lower burden of data capture and reduced floor and ceiling effects compared to traditional Patient Reported Outcomes Measurements (PROMs). We investigated the suitability of PROMIS Mobility score in assessing physical function in the sequelae of childhood hip disease. Methods. In all, 266 adolscents (aged ≥ 12 years) and adults were identified with a prior diagnosis of childhood hip disease (either Perthes’ disease (n = 232 (87.2%)) or Slipped Capital Femoral Epiphysis (n = 34 (12.8%)) with a mean age of 27.73 years (SD 12.24). Participants completed the PROMIS Mobility Computer Adaptive Test, the Non-Arthritic Hip Score (NAHS), EuroQol five-dimension five-level questionnaire, and the Numeric Pain Rating Scale. We investigated the correlation between the PROMIS Mobility and other tools to assess use in this population and any clustering of outcome scores. Results. There was a strong correlation between the PROMIS Mobility and other established PROMs; NAHS (rs = 0.79; p < 0.001). There was notable clustering in PROMIS at the upper end of the distribution score (42.5%), with less seen in the NAHS (20.3%). However, the clustering was broadly similar between PROMIS Mobility and the comparable domains of the NAHS; function (53.6%), and activity (35.0%). Conclusion. PROMIS Mobility strongly correlated with other tools demonstrating convergent construct validity. There was clustering of physical function scores at the upper end of the distributions, which may reflect truncation of the data caused by participants having excellent outcomes. There were elements of disease not captured within PROMIS Mobility alone, and difficulties in differentiating those with the highest levels of function. Cite this article: Bone Jt Open 2021;2(12):1089–1095

Objectives. The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. Methods. A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison. Results. The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison. Conclusion. This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs. Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628

Aims. Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Methods. Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. Results. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. Conclusion. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769–774

Aims. The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death. Methods. This was a retrospective cohort study of consecutive patients referred to the orthopaedic department at a UK trauma centre with a proximal femoral metastasis (PFM) over a seven-year period (2010 to 2016). The study group were compared to a matched control group of non-metastatic hip fractures. Minimum follow-up was one year. Results. There was a 90-day mortality of 46% in patients with metastatic hip fractures versus 12% in controls (89/195 and 24/192, respectively; p < 0.001). Mean time to surgery was longer in symptomatic metastases versus complete fractures (9.5 days (SD 19.8) and 3.4 days (SD 11.4), respectively; p < 0.05). Albumin, urea, and corrected calcium were all independent predictors of early mortality and were used to generate a simple tool for predicting 90-day mortality, titled the Metastatic Early Prognostic (MEP) score. An MEP score of 0 was associated with the lowest risk of death at 30 days (14%, 3/21), 90 days (19%, 4/21), and one year (62%, 13/21). MEP scores of 3/4 were associated with the highest risk of death at 30 days (56%, 5/9), 90 days (100%, 9/9), and one year (100%, 9/9). Neither age nor primary cancer diagnosis was an independent predictor of mortality at 30 and 90 days. Conclusion. This score could be used to predict early mortality and guide perioperative counselling. The delay to surgery identifies a potential window to intervene and correct these abnormalities with the aim of improving survival. Cite this article: Bone Joint J. 2020;102-B(1):72–81

The study aimed to determine how well recorded pain levels and range of motion relate to patients' reported levels of functional ability/disability pre- and post- total hip arthroplasty. Range of motion (ROM), Oxford Hip Score (OHS) and Self-Report Harris Hip Score (HHS) were recorded pre-operatively and 3 months post-total hip arthroplasty. Pearson's correlation coefficients were calculated to determine the strength of the relationships both pre- and post-operatively between ROM (calculated using the HHS scoring system) and scores on OHS and HHS and response relating to pain from the questionnaires (question 1 HHS and questions 1, 6, 8, 10, 11 and 12 of OHS) and overall scores. Only weak relationships were found between ROM and HHS pre- (r = 0.061, n = 99, p = 0.548) and post-operatively (r = 0.373, n = 66, p = 0.002). Similar results were found for OHS, and when ROM was substituted for flexion range. In contrast, strong correlations were found between OHS pain component and HHS pre- (r = -0.753, n = 107, p<0.001) and post-operatively (r = -0.836, n = 87, p<0.001). Strong correlations were also found between the OHS pain component correlated with the HHS functional component only (HHS with score for questions relating to pain deducted) pre- (r = -0.665, n = 107, p<0.001) and post-operatively (r = -0.688, n = 87, p<0.001). Similar results were found when the HHS pain component was correlated with OHS. In orthopaedic clinical practice ROM is routinely used to assess the success or failure of arthroplasty surgery. These results suggest that this should not be done. Instead, asking the patient the level of pain that they are experiencing may be a good determinant of level of function. The results of this study may aid the development of arthroplasty scoring systems which better assess patients' functional ability

Aims. The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. Methods. This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results. Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion. The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP. Cite this article: Bone Jt Open 2023;4(8):580–583

Osteoporosis is a common disorder characterized by low bone mass and reduced bone quality that affects the bone strength negatively and leads to increased risk of fracture. Bone mineral density (BMD) has been the standard instrument for the diagnosis of osteoporosis and the determination of fracture risk. Despite the approximation of the bone mass, BMD does not provide information about the bone structure. Trabecular bone score (TBS), which provides an indirect evaluation of skeletal microarchitecture, is calculated from dual X-ray absorptiometry and a simple and noninvasive method that may contribute to the prediction of osteoporotic fractures in addition to the measure of bone density. The goal of this study was to determine the mean TBS values in healthy postmenopausal women and the overall association between TBS and demographic features, bone mineral density of the lumbar spine and femoral neck and bone mineral density to body mass index ratio (BMD/BMI) of the lumbar spine. Fifty-three postmenopausal healthy women participated. The bone mineral density of the lumbar spine and femoral neck were measured dual X-ray absorptiometry. Anteroposterior lumbar spine acquisitions were used to calculate TBS for L1-L4. Age, height, weight, BMI and the ratio of BMD to BMI, which was considered to be a simple tool for assessing fracture risk in especially obese individuals, were calculated. The relationship between TBS and other variables was examined using Spearman's rank correlation coefficients. Mean BMD of the lumbar spine and the femoral neck were 0.945 ± 0.133 and 0.785 ± 0.112 g/cm2, respectively (Table 1). Mean TBS was 1.354 ± 0.107. There was a significant positive moderate correlation between TBS and total lumbar BMD/BMI ratio (r=0.595, pTBS values of postmenopausal women were negatively correlated with age and BMI and positively with bone mineral density and BMD/BMI ratio. The ratio between lumbar BMD and BMI presented a stronger correlation with TBS than that of BMD with TBS. Because of the better correlation, the BMD/BMI ratio may be used as a simple tool for the assessment of the risk of fractures. Further investigation may be needed to evaluate the factors influencing exercise intervention on TBS on this population of patients

Abstract. Abstract:. Background. The dissatisfaction rate in patients operated with TKR is generally quoted to be around 20% in various registries in patients operated by multiple surgeons. The data of satisfaction rates following a TKR performed by single high volume surgeons is lacking. Aim. To study the satisfaction rate and Net Promoter Score (NPS) of consecutively operated TKR patients by a single surgeon with a minimum 1 year follow up. Methods. 860 out of 883 patients who were operated between 1st April, 2018 and 31st March, 2019 were contacted by a telephonic call. They were asked 3 questions related to their experience about the operation. The patient satisfaction, NPS and reason for dissatisfaction were assessed. Results. The overall satisfaction rate of 95.93% and a net promoter score of +96.63 was observed. When the NPS was calculated as the worst case scenario, a score of +93.70 was observed. 6 patients were unsatisfied with causes directly related to the surgery. Conclusion. TKR can have as high satisfaction rates with very high NPS in experienced surgical hands using standard techniques. These results may form a benchmark against which newer technologies can be compared

Aims. The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). Methods. A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient’s MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. Results. The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. Conclusion. We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J 2021;103-B(5):971–975

The Nottingham Hip Fracture Score (NHFS) is validated to predict mortality after fragility neck of femur fractures (NOF). Risk stratification supports informed consent, peri-operative optimisation and case prioritisation. With the inclusion of fragility distal femur fractures (DFF) in the BPT, increasing attention is being placed on the outcome of these injuries. Developing on the lessons learnt over the past decades in NOF management is key. This study assesses the validity of the NHFS in predicting mortality after fragility DFFs. A multi-centre study of 3 high volume fragility fracture units was performed via a retrospective analysis of prospectively collected databases. Patients aged 60 years-of-age who presented with AO 33.A/B/C native DFF, or V.3.A/B periprosthetic DFF over an 86-month period between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Open and/or polytrauma (ISS >15) were excluded. All operations were performed or supervised by Consultant Orthopaedic Surgeons and were reviewed peri-operatively by a 7-day MDT. Patients with a NHFS of gt;=5 were stratified into a high-risk of 30-day mortality cohort, with all others being œlow-risk. 285 patients were eligible for inclusion with 92 considered to be low-risk of 30-day mortality, these tended to be younger female patients admitted from their own homes. 30-day mortality was 0% in the low-risk cohort and 6.2% (12/193) in the high-risk group. 1-year mortality was 8.7% (8/92) and 35.7% (69/193) in the low and high-risk groups respectively. Area Under the Curve (AUC) analyses of Receiver Operator Characteristic (ROC) curves demonstrated the greatest ability to predict mortality at 30-days for the high-risk cohort (0.714). The NHFS demonstrates a good ability to predict 30-day mortality in those patients with a NHFS =5 after a surgically managed fragility DFF. With comparable mortality outcomes to those documented from fragility NOF

INTRODUCTION: The American Knee Society score (AKSS) and the Oxford Knee score (OKS) are widely used health outcome measures for total knee replacements. The AKSS is a surgeon-assessed, variable weighted knee score. The OKS is a patient assessed equally weighted score. Our aim was to evaluate whether patient self assessment is a viable alternative to clinical review and whether it can provide enough information to identify which patient would require a clinic visit. As there had been no previous studies correlating the two scoring systems, we investigated whether a correlation exists between the two scores at 2, 5 and 10 year periods. A correlation would allow us to determine what OKS value would achieve 90% sensitivity in identifying patients requiring clinical review at the above time points. This strategy would reduce the number of clinical visits required and its associated cost. METHODS: We reviewed the data gathered prospectively from January 2000 to April 2006. All patients were part of an ongoing multi-surgeon single institution Knee Arthroplasty Outcome Programme. Preoperative, 2, 5 and 10 year post-operative OKS and AKSS were gathered from different cohorts. This method of comparison has been validated by previous publications. The scores were then analyzed using the Pearson correlation and linear regression. Different OKS values were analyzed for sensitivity and specificity. RESULTS: 175 patients completed both the OKS and AKSS questionnaires preoperatively. 312 completed both scores at 2 years; 124 at 5 years and 57 patients at 10 years. The mean OKS, and the two AKSS components, the Knee score and Functional score improved significantly 2 years postoperatively when compared to their preoperative values. The Functional score deteriorated significantly from 5 to 10 years (p< 0.0001). There was good correlation between the OKS and the Knee score and Functional score at 2 years and a moderate correlation at 5 to 10 years. OKS > 24 showed more than 90 % sensitivity in identifying poor Knee scores in the 2, 5 and 10 year periods. CONCLUSION: In this study, the good correlation of OKS and AKSS at 2-years suggests that postal Oxford questionnaire is sufficient in following up patients in the short term after total knee replacement. However, the moderate correlation at 5 and 10 years suggests that clinical evaluation is necessary. We recommend that at 2 years, all patients complete an OKS questionnaire and if this is above 24, a clinical evaluation maybe required. Using this OKS value as a screening technique would allow a reduction of up to 50% in clinic visits and outpatient costs at the 2 year follow-up. This reduction is not as great at the 5 and 10 year periods. At these time periods, we recommend a clinical follow-up

The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was developed in 2004 to risk-stratify patients with soft tissue infections using common blood tests when the clinical picture is equivocal. A score ≥ 6 conferred a positive predictive value (PPV) of 92% and negative predictive value of 96% for necrotising fasciitis. We retrospectively calculated LRINEC scores for Orthopaedic patients admitted to ITU in our hospital with limb soft-tissue infection and confirmed Group-A Streptococcus or Staphylococcus in fluid, blood, tissue or swab culture between 2010–2017 (n=10). Mean age = 57.4 and 60% were female. Half of all patients died during admission. Mean LRINEC score of all patients was 5.3±3.1 (median = 6). Mean score in deceased patients was 4.8±2.8 (scores: 0,5,6,6,7; median = 6); in discharged patients mean = 5.8±3.7 (scores: 0,5,7,7,10; median = 7). 6 patients had a score ≥6, making our PPV 60%. 4 patients had necrotising fasciitis confirmed on histology (LRINEC scores = 0,5,7,10). Our PPV of 60% is less than the figure obtained in the original paper. 2 patients with a LRINEC score <6 died during admission, including a patient with a score of 0. Furthermore, a patient with necrotising fasciitis confirmed on histology also had a LRINEC score of 0. We conclude that LRINEC scores should not delay surgery when clinical suspicion is high, and should be used as an adjunct to clinical decision-making, rather than a replacement, as patients with low LRINEC scores can also have confirmed necrotising fasciitis and poor outcomes

Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. Recent NICE guidelines, and clinical targets have all focused on decreasing in hospital death from acquired SVTE. Despite these guidelines there are no large studies investigating the risk factors for or incidence of SVTE in acute trauma admission. Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution was used to construct a risk score for SVTE. Twenty three factors were screened with pairwise analysis. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a risk score and correct for confounding variables from nine significant factors identified by the pairwise analysis. Four factors; length of stay; chest infection; cardiac failure and transfusion were used to produce the final risk score. The score was statistically significant (p< 0.0001) and highly predictive (ROC analysis, AUC=0.76) of SVTE. The score was separately validated in two cohorts from different Level 1 trauma centres. In one prospective consecutive cohort of 1000 NOF patients all components of the Nottingham SVTE score were found to be individually statistically significant (p< 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive in this patient cohort. Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of thromboembolic events, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions

This study investigates the use of the Metabolic Equivalent of Task (MET) score in a hip arthroplasty population and its ability to capture additional benefit beyond the maximum Oxford Hip Score (OHS). OHS, EuroQol-5D index (EQ-5D), and the MET were prospectively recorded in 221 primary hip arthroplasty procedures pre-operatively and at 1-year. The distribution was examined reporting the presence of ceiling & floor effects. Validity was assessed correlating the MET with the other scores using Spearman's rank and determining responsiveness using the standardised response mean (SRM). A subgroup of 93 patients scoring 48/48 on the OHS were analysed by age group, sex, BMI and pre-operative MET using the other two metrics to determine if differences could be established despite all scoring identically on the OHS. 117 total hip and 104 hip resurfacing arthroplasty operations were included. Mean age was 59.4 ± 11.3. Post-operatively the OHS and EQ-5D demonstrate significant negatively skewed distributions with ceiling effects of 41% and 53%, respectively. The MET was normally distributed post-operatively with no ceiling effect. Weak-moderate but statistically significant correlations were found between the MET and the other two metrics both pre & post-operatively. Responsiveness was excellent, SRM for OHS: 2.01, EQ-5D: 1.06 and MET: 1.17. In the 48/48 scoring subgroup, no differences were found comparing groups with the EQ-5D, however significantly higher MET scores were demonstrated for patients aged <60 (12.7 vs 10.6, p=0.008), male patients (12.5 vs 10.8, p=0.024) and those with pre-operative MET scores >6 (12.6 vs 11.0, p=0.040). The MET is normally distributed in patients following hip arthroplasty, recording levels of activity which are undetectable using the OHS. As a simple, valid activity metric, it should be considered in addition to conventional PROMs in order to capture the entire benefit experienced following hip arthroplasty

Aims. Glenoid bone loss can be a challenging problem when revising a shoulder arthroplasty. Precise pre-operative planning based on plain radiographs or CT scans is essential. We have investigated a new radiological classification system to describe the degree of medialisation of the bony glenoid and that will indicate the amount of bone potentially available for supporting a glenoid component. It depends on the relationship between the most medial part of the articular surface of the glenoid with the base of the coracoid process and the spinoglenoid notch: it classifies the degree of bone loss into three types. It also attempts to predict the type of glenoid reconstruction that may be possible (impaction bone grafting, structural grafting or simple non-augmented arthroplasty) and gives guidance about whether a pre-operative CT scan is indicated. Patients and Methods. Inter-method reliability between plain radiographs and CT scans was assessed retrospectively by three independent observers using data from 39 randomly selected patients. . Inter-observer reliability and test-retest reliability was tested on the same cohort using Cohen's kappa statistics. Correlation of the type of glenoid with the Constant score and its pain component was analysed using the Kruskal-Wallis method on data from 128 patients. Anatomical studies of the scapula were reviewed to explain the findings. Results. Excellent inter-method reliability, inter-observer and test-retest reliability were seen. The system did not correlate with the Constant score, but correlated well with its pain component. . Take home message: Our system of classification is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty. Cite this article: Bone Joint J 2016;98-B:374–80

Background. Neurogenic claudication is a well recognised symptom of spinal stenosis. Pain in the lower limbs and back limit walking speed and distance. Outcome of treatment should be easily measurable, but in practice is not. Walking tests are difficult to perform reliably. It is possible to measure speed and endurance with a treadmill, but this is expensive, of doubtful reliability, and many elderly patients are reasonably worried about falling off. Commonly used back pain outcome questionnaires are probably invalid for this population, and few questionnaires have been designed specifically for this complaint. The purpose of this study was to evaluate 3 questionnaires (Swiss Spinal Stenosis Score (SSS), Oxford Claudication Score (OCS) and Oswestry Disability Index (ODI)) and a Shuttle Walking Test (SWT). The Shuttle Walking Test, developed originally in respiratory medicine, shows promise as both a clinical measure and outcome measure for patients with neurogenic claudication. In an internal study, we have found that none of our patients selected for surgery can manage more than 200 metres. A fit adult can usually manage about 600 metres on this test. Study Design: Shuttle Walking Test (SWT), Swiss Spinal Stenosis Score (SSS), Oxford Claudication Score (OCS) and Oswestry Disability Index (ODI) were administered to patients with lumbar spinal stenosis (LSS) and neurogenic claudication. Objective: To determine reliability of SWT, SSS (Q1–12), OCS and ODI in LSS assessment. Methods: Thirty two clinic patients with LSS were assessed twice with one week between assessments to determine reliability. Retrospective data from 17 patients assessed before and 18 months after surgery for LSS were used to investigate use of reliability in a clinical setting. Results: Test-retest reliability was 0.92 for SWT, 0.92 for SSS, 0.83 for OCS and 0.89 for ODI (Intraclass correlation coefficient). Mean scores (percent) were SSS 51, OCS 45 and ODI 40. For 95% certainty of change between assessments for a single patient, SSS would need to change by 15, OCS by 20 and ODI by 16. Mean SWT was 150m, with change of 76m required for 95% confidence. Cronbach’s alpha was 0.91 for SSS, 0.90 for OCS and 0.89 for ODI. Change in ODI correlated most strongly with patient satisfaction after surgery (_=0.80, p< 0.001). Conclusions: Fluctuations in patient’s symptoms result in wide individual confidence intervals. Performance of SSS, OCS and ODI questionnaires are broadly similar. The condition specific SSS is most precise but not much better than the non-specific ODI. SWT gives a snapshot of physical function which is acceptable for group analysis. Use of SWT for individual assessment after surgery is feasible but multiple testing would improve sensitivity for change

While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR). Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients. The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients. For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR

While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR). Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients. The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients. For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR

Patients' perspective and experience is heavily modulated by their understanding of their pre-operative disability along with their overall coping strategy and life philosophy. Given that evidence-based practice is relying on patient-reported outcomes more and more, the orthopaedic community must be diligent in differentiating patients that may have the same objective outcome but vary widely on a patient-reported subjective basis. In clinical practice, patient selection is often a sensitive, experience-based decision process that screens for catastrophization, recognizing that certain patients will not benefit from a simple surgery. It is well appreciated that patient's catastrophization can affect their subjective outcome but there is little reported literature on this abstract concept. The study set out to determine if post-operative outcomes correlated with pre-operative catastrophization scales. This current study set out to look at a cohort of complex consecutive foot and ankle cases and describe the relationship between Patient Catastrophizing Score (PCS) and multiple functional outcomes that are used commonly in foot and ankle specifically (SF-12 & FAOS). The PCS has three subcategory rumination, helplessness and magnification. A single institution undertook recruitment in consecutive patients within three surgeon's practice. In the end, 46 patients were found to be eligible in the study with an average age of 54.72 ± 14.41 years-old, a majority female 30 / 46 (65.22%), a minority employed at the pre-operative visit 19/46 (41%) and with an average BMI of 26.2 ± 5.56. We found that the mental component of the SF12 had a statistically significant negative effect with the rumination score (r=−1.03) (p = 0.01) and the helplessness score (r=−1.05) (0.001). There was no statistically significant effect for the physical component of the SF-12. Looking at the FAOS Pain component, it correlated was significantly with the PCS rumination (Multivariate : r= −7.6 (p=0.002) Univariate: r=−2 (0.03)) and helplessness (Multivariate : r=−6.73 (p=0.01) Univariate: r=−1.5 (p=0.03)). Otherwise the FAOS ADL component showed correlation as well with the PCS rumination (Multivariate: r=−4.67 (p=0.02) Univariate : r=−1.85 (p=0.01)), helplessness (Multivariate r=−5.89 (p = 0.01) Univariate r=−1.81 (p = 0.001)) and total score (Multivariate : r=3.74 (p=0.02) Univariate r=−0.75 (p=0.01)). The FAOS Quality of life component was statistically significant for the rumination score (Univariate r=−11.59) (p < 0.05) and the helplessness score (Univariate r=−9.65) (p = 0.002) also the PCS total (Univariate r=8.54) (p = 0.0003). As layed out in our hypothesis, this study did show an association between an increase patient catastrophizing score pre-operatively and a worse outcome in the following scores: Mental component of SF12, FAOS Pain, FAOS ADL and FAOS Quality of life components. This is an association and no causality can be proven within the limits of this current pilot study, but remains alarming. In elective surgeries, catastrophization should be screened for using the PCS form and potentially modulated pre-operatively with the help of allied health therapist while a patient is on the waitlist

Aims. Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. Methods. We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman’s correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting. Results. The mean follow-up was 11.4 months (3 to 31). The mean time to union was 9.7 months (3 to 21), the mean number of operations was 2.8 (1 to 11), the mean time in hospital was 17.7 days (5 to 84), the mean length of treatment was 92.7 days (5 to 730), the mean number of admissions was 1.7 (1 to 6), and the mean functional score (Lower Extremity Functional Score (LEFS)) was 60.13 (33 to 80). There was a significant correlation between the GHS and each of the outcome measures. A predictive model was generated from which the GHS could be used to predict the various outcome measures. Conclusion. The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. Our model generates a numerical value for each outcome measure that can be used in clinical practice to inform the treating team and to advise patients. Cite this article: Bone Joint J 2020;102-B(1):26–32

The regenerative potential of bone is enormous, and it is possible to lengthen limbs by bone distraction. However, there remains a major risk of fracture after lengthening the bone. Previous studies have described how the pixel value ratio may be used for determining the time for frame removal. The aim of this study was to investigate the intrarater and the interrater reliability of pixel value scores from radiographs in tibial lengthening prior to frame removal. Moreover, the study aimed to determine the overall number of X- rays obtained during circular frame treatment. Retrospective study. Patients treated with tibial lengthening by a circular frame at Aalborg University Hospital from January 1st 2000 to December 31st 2017 and a minimum of 12 months after frame removal were included. The bone was divided in proximal-, regenerate- and distal bone zone. These 3 zones were in AP x-ray divided in an anterior and posterior zone and in sagittal X-ray medial and lateral zone producing 6 zones in which the pixel value was measured. Pixel value ratio was calculated as: (Proximal pixel value+Distal pixel value)/2/Regenerate pixel value. Interrater correlations were calculated from measurements obtained by an orthopaedic registrar and an orthopaedic specialist. Intrarater correlation was calculated from repeated measurements obtained by an orthopaedic specialist. Mean duration of circular frame treatment was: 6 (+-3) months. Median number of x-ray controls during frame treatment were: 9 (+-4). Out of 90 tibial lengthening it was only possible to measure pixel value in all six areas of interest on 20 lengthening prior to frame removal. Major reasons for inability to obtain measurements were metal hardware crossing the areas of bone interest on x-rays. The mean (95 % confidence intervals) pixel ratios values were: 1) lateral: 0.96 (0.93–1.00); 2) medial: 0.95 (0.92–0.99); 3) anterior: 0.94 (0.90–0.97); 4) posterior: 0.96 (0.93–0.99). The mean (95 % confidence intervals) inter ratter ICC estimates were: 1) lateral: 0.8 (0.5–0.9); 2) medial: 0.8 (0.4–0.9); 3) anterior: 0.4 (−0.5–0.8); 4) posterior: 0.6 (0.1–0.9). The mean (95 % confidence intervals) intra ratter ICC estimates were: 1) lateral: 1.0 (0.9–1.0); 2) medial: 1.0 (1.0–1.0); 3) anterior: 0.9 (0.9–1.0); 4) posterior: 1.0 (1.0–1.0). Out of the 20 lengthening examined one fracture occurred in the bone regenerate after frame removal. Prospective studies are warranted to determine whether the pixel value ratio can be used as an indicator for frame removal

Aims. The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury. Patients and Methods. Initially, 20 patients with radiographs six weeks following a humeral shaft fracture were selected at random from a trauma database and scored by three observers, based on the Radiographic Union Scale for Tibial fractures system. After refinement of the RUSHU criteria, a second group of 60 patients with radiographs six weeks after injury, 40 with fractures that united and 20 with fractures that developed nonunion, were scored by two blinded observers. Results. After refinement, the interobserver intraclass correlation coefficient (ICC) was 0.79 (95% confidence interval (CI) 0.67 to 0.87), indicating substantial agreement. At six weeks after injury, patients whose fractures united had a significantly higher median score than those who developed nonunion (10 vs 7; p < 0.001). A receiver operating characteristic curve determined that a RUSHU cut-off of < 8 was predictive of nonunion (area under the curve = 0.84, 95% CI 0.74 to 0.94). The sensitivity was 75% and specificity 80% with a positive predictive value (PPV) of 65% and a negative predictive value of 86%. Patients with a RUSHU < 8 (n = 23) were more likely to develop nonunion than those with a RUSHU ≥ 8 (n = 37, odds ratio 12.0, 95% CI 3.4 to 42.9). Based on a PPV of 65%, if all patients with a RUSHU < 8 underwent fixation, the number of procedures needed to avoid one nonunion would be 1.5. Conclusion. The RUSHU is reliable and effective in identifying patients at risk of nonunion of a humeral shaft fracture at six weeks after injury. This tool requires external validation but could potentially reduce the morbidity associated with delayed treatment of an established nonunion. Cite this article: Bone Joint J 2019;101-B:1300–1306

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand. The Oxford Knee Score (OKS) is a 12-item questionnaire used to track knee arthroplasty outcomes. Validation of such patient reported outcome measures is typically anchored to a single question based on patient ‘satisfaction’, however risk of subsequent revision surgery is also an important outcome measure. The OKS can predict subsequent revision risk within two years, however it is not known which item(s) are the strongest predictors. Our aim was to identify which questions were most relevant in the prediction of subsequent knee arthroplasty revision risk. . All primary TKAs (n=27,708) and UKAs (n=8,415) captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months, five years or ten years post-surgery were included. Logistic regression and receiver operating characteristics (ROC) curves were used to assess prediction models at six months, five years and ten years. Q1 ‘overall pain’ was the strongest predictor of revision within two years (TKA: 6 months, odds ratio (OR) 1.37; 5 years, OR 1.80; 10 years, OR 1.43; UKA: 6 months, OR 1.32; 5 years, OR 2.88; 10 years, OR 1.85; all p<0.05). A reduced model with just three questions (Q1, Q6 ‘limping when walking’, Q10 ‘knee giving way’) showed comparable or better diagnostic ability with the full OKS (area under the curve (AUC): TKA: 6 months, 0.77 vs. 0.76; 5 years, 0.78 vs. 0.75; 10 years, 0.76 vs. 0.73; UKA: 6 months, 0.80 vs. 0.78; 5 years: 0.81 vs. 0.77; 10 years, 0.80 vs. 0.77). The three questions on overall knee pain, limping when walking, and knee ‘giving way’ were the strongest predictors of subsequent revision within two years. Attention to the responses for these three key questions during follow-up may allow for prompt identification of patients most at risk of revision

Patients undergoing hip resurfacing arthroplasty (HRA) is typically reserved for highly active patients. Patient Reported Outcome Measures (PROMs) such as the Oxford Hip Score (OHS) are reported to have ceiling effects, which may limit physicians' ability to measure health gain in these patients. The Metabolic Equivalent of Task (MET) index is a validated compendium assigning energy expenditure to a wide range of activities; for example, a slow walk expends 2.9 kcal/kg/hour, golf expends 4.0 kcal/kg/hour, while moderate lacrosse typically expends 8.1 kcal/kg/hour. We hypothesized that for patients with high OHS (47–48) after HRA, the MET index could better discriminate between high-performing individuals. We evaluated 97 consecutive HRA patients performed by a single surgeon. They prospectively completed an online Oxford Hip Score. They also listed three activities which they had performed independently in the preceding 2 weeks with a Likert-scale slider denoting intensity of effort. Matched data-sets were obtained from 51 patients, from which 23 had OHS of 47–48 at 6-months. Their activity with the highest MET index was selected for analysis. The 23 patients' OHS improved from 29.3 ± 7.0 preoperatively to 47.6 ± 0.5 after 6-months, while their MET indices improved from 8.5 ± 3.7 to 12.9 ± 3.5 kcal/kg/hr. The activities performed by these high-performance individuals ranged from the lowest, pilates (8.05 kcal/kg/hour), to highest, running at 22km/hr (23 kcal/kg/hour). 45% of patients undergoing HRA in this cohort had OHS of 47 and 48 at 6-months after surgery. Unlike the OHS, the MET index described variation in physical activity in these high-performance individuals, and did so on an objective measurable scale

Introduction. Our study aimed to correlate Forgotten Joint Socre(FJS) preoperatively(Preop-FJS) and postoperatively(Postop-FJS), hypothesis being that patients with high Preop-FJS had more likelihood of poor Postop-FJS. Material & Methods. We retrospectively identified 212 patients, having undergone uniform primary TKA by a single surgeon over 20 months, with complete data of FJS and New Knee Society Score (NKSS), recorded preoperatively and postoperatively(1year±1month). Mean age was 66.3 years, with 167 female and 45 males. We correlated Preop-FJS to Postop-FJS using Spearmans correlation test. For our hypothesis, we studied patients using two cutoffs for Preop-FJS, first set with median Preop-FJS cutoff of 35 and second set with median Preop-FJS cutoff of 40. We applied Mann Whitney U test to compare Postop-FJS. SPSS software V15.0 was used. Results. Median Preop-FJS was 14.1(Range=0–81.3;IQR=6.3,25). Median Postop-FJS was 55.9(Range=2.1–100;IQR=42.2,78.6). Spearman Correlation Coefficient(rho) between them was(−)0.04, statistically not significant(p=0.53) but suggesting an inverse association. On studying Preop-FJS cutoff of 35, 20 patients having Preop-FJS>35 showed corresponding Postop-FJS of 50; remaining 192 patients with Preop-FJS≤35 showed corresponding Postop-FJS of 56.8. The difference in Postop-FJS was not statistically significant(p= 0.16). On studying Preop-FJS cutoff of 40, 11patients having Preop-FJS>40 showed corresponding Postop-FJS of 43.7; remaining 201 patients with Preop-FJS≤40 showed corresponding Postop-FJS of 56.8; the difference in Postop-FJS being statistically significant(p= 0.04). On comparison, patients with Preop-FJS≤40 showed significant improvement(p=0.001) in Postop-FJS, while patients with Preop-FJS>40 showed no improvement(p=0.2). Discussion and Conclusion. So far no study establishes the relationship between preoperative and postoperative FJS. Our hypothesis was confirmed that if Preop-FJS was high, i.e. patient perceived his arthritic joint as normal in daily activities, then he was likely to have a poor Postop-FJS, consequently unable to accept the artificial joint as normal. In clinical practice, to avoid dissatisfaction we now additionally counsel patients with Preop-FJS>40

Aims. The primary aim of this study was to assess whether pain in the contralateral knee had a clinically significant influence on the outcome of total knee arthroplasty (TKA) according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary aims were to: describe the prevalence of contralateral knee pain; identify if it clinically improves after TKA; and assess whether contralateral knee pain independently influences patient satisfaction with their TKA. Methods. A retrospective cohort of 3,178 primary TKA patients were identified from an arthroplasty database. Patient characteristics, comorbidities, and WOMAC scores were collected preoperatively and one year postoperatively for the index knee. In addition, WOMAC pain scores were also collected for the contralateral knee. Overall patient satisfaction was assessed at one year. Preoperative contralateral knee pain was defined according to the WOMAC score: minimal (> 78 points), mild (59 to 78), moderate (44 to 58), and severe (< 44). Multivariate regression analysis was used to adjust for confounding. Results. According to severity there were 1,425 patients (44.8%) with minimal, 710 (22.3%) with mild, 518 (16.3%) with moderate, and 525 (16.5%) with severe pain in the contralateral knee. Patients in the severe group had a greater clinically significant improvement in their functional WOMAC score (9.8 points; p < 0.001). Only patients in the moderate (22.9 points) and severe (37.8 points) groups had a clinically significant improvement in their contralateral knee pain (p < 0.001), but they were significantly less likely to be satisfied with their TKA (moderate: odds ratio (OR) 0.64, 95% confidence interval (CI) 0.4 to 0.92, p = 0.022; severe: OR 0.57, 95% CI 0.39 to 0.82, p = 0.002). Conclusion. Contralateral knee pain did not impair improvement in the WOMAC score after TKA, and patients with the most severe contralateral knee pain had a clinically significantly greater improvement in their functional outcome. More than half the patients presenting for TKA had mild-to-severe contralateral knee pain, most of whom had a clinically meaningful improvement but were significantly less likely to be satisfied with their TKA. Cite this article: Bone Joint J. 2020;102-B(1):125–131

Introduction. Patient Reported Outcome Measures (PROMs) are used as outcome of many surgical treatments such as Hip and knee joint replacements, varicose vein and groin hernia surgery. Outcome scores in orthopaedics tend to be site and/or pathology specific. Trauma related pathology uses a surrogate outcome scores. A unified outcome score for trauma is needed to help with the measurement of outcomes in trauma patients and evaluate the actual impact that trauma inflicts to patients' lives. Materials & Methods. We have designed a PROM especially for Trauma patients, in order to measure the extent of recovery to pre-injury state. This score uses as baseline the pre-injury status of the patient and has the aim to determine the percentage of rehabilitation after any form of treatment. This PROM is not site specific and can be used for every Trauma condition. It uses simple wording, user friendly and accessed via phone conversation. The outcome score consists of eleven questions. The first ten questions use the 5-point Likert scale and the final question a scale from zero to ten. The questions are divided into three subgroups (Symptoms, Function and Mental status). The final question assesses the extent of return to pre-injury status. The SF-12v2 questionnaire was used for the validation of the COST questionnaire. We gathered COST and SF-12v2 questionnaires from patients who were at the end of their follow-up after treatment for various trauma conditions, treated either conservatively either operatively. Results. A total of 50 COST questionnaires were gathered in out outpatients department. The participants were 33 male and 17 female patients (aged 44.2 ±18.9 years) and the questionnaires collected at mean 9.7 months post-injury. A Cronbach's Alpha value of 0.89 was identified for the whole construct. The three dimensions of the scale had good internal consistency as well (Cronbach's Alpha test values 0.73, 0.85 and 0.81 for symptoms, function and mental status respectively). Strong/moderate correlation (Spearman's Rho test 0.45–0.65) was observed between the respective physical/mental dimensions of the COST and SF-12v2 questionnaires. Conclusion. There is a need for a specific PROM for Trauma pathology which is not site specific and easy to use and understand. COST is a useful tool to Trauma surgeons to measure the outcomes of their patients and has high internal consistency

Aims. The aim of this study was to compare patient-reported outcome measures (PROMs) and the Single Assessment Numerical Evaluation (SANE) score in patients treated with a volar locking plate for a distal radial fracture. Methods. This study was a retrospective review of a prospective database of 155 patients who underwent internal fixation with a volar locking plate for a distal radial fracture between August 2014 and April 2017. Data which were collected included postoperative PROMs (Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and Patient-Rated Wrist Evaluation (PRWE)), and SANE scores at one month (n = 153), two months (n = 155), three months (n = 144), six months (n = 128), and one year (n = 73) after operation. Patients with incomplete data were excluded from this study. Correlation and agreement between PROMs and SANE scores were evaluated. Subgroup analyses were carried out to identify correlations according to variables such as age, the length of follow-up, and subcategories of the PRWE score. Results. The Pearson correlation coefficient (r) between PROMs and SANE scores was -0.76 (p < 0.001) for DASH and -0.72 (p < 0.001) for PRWE, respectively. Limits of agreement between PROMs and ‘100-SANE’ scores were met for at least 93% of the data points. In subgroup analysis, there were significant negative correlations between PROMs and SANE scores for all age groups and for follow-up of more than six months. The correlation coefficient between PRWE subcategories and SANE score was -0.67 (p < 0.001) for PRWE pain score and -0.69 (p < 0.001) for PRWE function score, respectively. Conclusion. We found a significant correlation between postoperative SANE and PROMs in patients treated with a volar locking plate for a distal radial fracture. The SANE score is thus a reliable indicator of outcome for patients who undergo surgical treatment for a radial fracture. Cite this article: Bone Joint J 2020;102-B(6):744–748

Aims. This study aimed to evaluate the association between the sagittal alignment of the femoral component in total knee arthroplasty (TKA) and new Knee Society Score (2011KSS), under the hypothesis that outliers such as the excessive extended or flexed femoral component were related to worse clinical outcomes. Methods. A group of 156 knees (134 F:22 M) in 133 patients with a mean age 75.8 years (SD 6.4) who underwent TKA with the cruciate-substituting Bi-Surface Knee prosthesis were retrospectively enrolled. On lateral radiographs, γ angle (the angle between the distal femoral axis and the line perpendicular to the distal rear surface of the femoral component) was measured, and the patients were divided into four groups according to the γ angle. The 2011KSSs among groups were compared using the Kruskal-Wallis test. A secondary regression analysis was used to investigate the association between the 2011KSS and γ angle. Results. According to the mean and SD of γ angle (γ, 4.0 SD 3.0°), four groups (Extended or minor flexed group, −0.5° ≤ γ < 2.5° (n = 54)), Mild flexed group (2.5° ≤ γ < 5.5° (n = 63)), Moderate flexed group (5.5° ≤ γ < 8.5° (n = 26)), and Excessive flexed group (8.5° ≤ γ (n = 13)) were defined. The Excessive flexed group showed worse 2011KSSs in all subdomains (Symptoms, Satisfaction, Expectations, and Functional activities) than the Mild flexed group. Secondary regression showed a convex upward function, and the scores were highest at γ = 3.0°, 4.0°, and 3.0° in Satisfaction, Expectations, and Functional activities, respectively. Conclusion. The groups with a sagittal alignment of the femoral component > 8.5° showed inferior clinical outcomes in 2011KSSs. Secondary regression analyses showed that mild flexion of the femoral component was associated with the highest score. When implanting the Bi-Surface Knee prosthesis surgeons should pay careful attention to avoiding flexing the femoral component extensively during TKA. Our findings may be applicable to other implant designs. Cite this article: Bone Joint J 2020;102-B(6 Supple A):36–42

A large proportion of wait times for primary total knee (TKA) and hip (THA) arthroplasty is the time from primary care referral to surgical consultation. To our knowledge, no study has investigated whether a referral Oxford Knee or Hip Score (OKHS) could be used to triage non-surgical referrals appropriately. The primary purpose of the current study was to determine if a referral OKHS has the predictive ability to discriminate when a knee or hip referral will be deemed conservative as compared to surgical by the surgeon during their first consultation, and to identify an OKHS cut-off point that accurately predicts when a primary TKA or THA referral will be deemed conservative. We retrospectively reviewed all consecutive primary TKA and THA consultations from a single surgeon's tertiary, high volume practice over a three-year period. Patients with a pre-consultation OKHS, BMI < 4 1, and no absolute contraindication to TJR were included. Consultation knees/hips were categorized into two groups based on surgeon's decision, those that were offered TJR during their first consolation (surgical) versus those that were not (conservative). Baseline demographic data and OKHS were abstracted. Variables of interest were compared between cohorts using the exact chi-square test and Wilcoxon rank-sum test. Spearman's rank correlation coefficients were used to measure association between pre-consult OKHS and the surgeon's decision. A receiver operator characteristic (ROC) curve analysis was used to calculate the area under the curve (AUC) and to identify a cut-off point for the pre-operative OKHS that identified whether or not a referral was deemed conservative. TKA and THA referrals were analyzed separately. The study included 1,436 knees (1,016 patients) with a median OKS of 25 (IQR 19–32) and 478 hips (388 patients) with a median OHS of 22 (IQR 16–29). Median pre-consultation OKHS demonstrated clinically and statistically significant differences between the surgical versus conservative cohorts (p 32 (sensitivity=0.997, NPV=0.992) and for hips is OHS >34 (sensitivity=0.997 NPV=0.978). ROC analysis identified severable potential lower OKHS thresholds, depending on weight of prioritization of sensitivity, specificity, and NPV. Referral OKS and OHS demonstrate good ability to discriminate when a primary TKA or THA referral will be deemed non-surgical versus surgical at their first consultation in a single surgeon's practice. Multiple potential effective OKHS thresholds can be applied as a tool to decrease wait times for primary joint arthroplasty. However, a cost analysis would aid in identifying the optimal cut-off score, and these findings need to be externally validated before they can be broadly applied

Introduction. The systematic effects of joint replacement in rheumatoid arthritis (RA) patients are that inflamed synovium and pathological articular cartilage has dissipated. Expectations of total knee arthroplasty (TKA) are reduction of inflammatory cytokines, decreased disease activity and improvement of drug efficacy and ADL. Remission of rheumatoid arthritis is defined as having a Disease Activity Score DAS28 (ESR) of less than 2.6 and Health Assessment Questionnaire (HAQ) – Disability Index, less than 0.5. Purpose. We investigated whether TKA could reduce disease activity and improve ADL, and subsequent remission levels of DAS and HAQ or not. Material and Methods. We analyzed the Knee Society Score (KSS), KOOS score and DAS28 in 15 patients, 23 rheumatoid arthritic knees at pre-operation and 1 year after operation. Preoperatively patients had used non-steroidal anti-inflammatory drugs, prednisolone, disease-modifying anti-rheumatic drugs including methotrexate. TKA (Zimmer NexGen LPS Flex Knee implants and Stemmed Tibial component with stem) was performed with the modified gap technique or modified anatomical technique using original tensor with synovectomy. Results. Preoperative and postoperative KSS are 45.7±18.1 and 88.7±17.7 (P<0.01) respectively, and function scores were 40.1±21.7 and 74.8±24.0 (P<0.01) respectively (Figure 1). Preoperative and postoperative KOOS score (%) were ‘pain’ 50.6±37.8 and 95.4±19.3 (P<0.01), ‘symptom’ 56.6±32.8 and 94.7±18.6 (P<0.01), ‘ADL’ 60.6±27.9 and 89.5±32.4 (P<0.01), ‘QOL’ 28.4±32.1 and 63.6 ±22.9 (P<0.01) and ‘sport’ 20.56±29.52 and 47.10±33.9(P=0.06), respectively (Figure 2). Preoperative and postoperative DAS28(CRP) were 4.48±1.08 and 3.58±1.11(P<0.01), and DAS28 (ESR) were 4.90±1.02 and 4.13±0.99 (P=0.02) (Figure 3). Discussion. Each scores except ‘sport’ and DAS28 (ESR) improved statistically 1 year after operation. Function score, ‘ADL’ and ‘QOL’ scores also improved. HAQ score includes 2 categories related to walking ability and TKA was expected to improve the HAQ score, although the HAQ score is highly affected by upper arm function. The ‘sport’ score did not improve because almost all patients did not do sports preoperatively and postoperatively. DAS28 (ESR) and DAS28 (CRP) correlate strongly, but in this study there were statistical discrepancies in improvement. This might be because age, sex, disease duration, and existence of rheumatoid factors, anti-cyclic citrullinated peptide antibody and DLA-DRB1 shared epitope have been shown to influence ESR. DAS28 improved by a little less than 1.0, but there was limited control of disease activity. It was reported that the average DAS 28 didn't drop below 3.2 in 3 years follow-up after TKA. In this study we did not assess depending on preoperative disease activity, but it was reported that TKA had a systematic effect on severe or moderate RA activity, not low disease activity

Aims. The stability of cementless acetabular components is an important factor for surgical planning in the treatment of patients with pelvic osteolysis after total hip arthroplasty (THA). However, the methods for determining the stability of the acetabular component from pre-operative radiographs remain controversial. Our aim was to develop a scoring system to help in the assessment of the stability of the acetabular component under these circumstances. Patients and Methods. The new scoring system is based on the mechanism of failure of these components and the location of the osteolytic lesion, according to the DeLee and Charnley classification. Each zone is evaluated and scored separately. The sum of the individual scores from the three zones is reported as a total score with a maximum of 10 points. The study involved 96 revision procedures which were undertaken for wear or osteolysis in 91 patients between July 2002 and December 2012. Pre-operative anteroposterior pelvic radiographs and Judet views were reviewed. The stability of the acetabular component was confirmed intra-operatively. Results. Intra-operatively, it was found that 64 components were well-fixed and 32 were loose. Mean total scores in the well-fixed and loose components were 2.9 (0 to 7) and 7.2 (1 to 10), respectively (p < 0.001). In hips with a low score (0 to 2), the component was only loose in one of 33 hips (3%). The incidence of loosening increased with increasing scores: in those with scores of 3 and 4, two of 19 components (10.5%) were loose; in hips with scores of 5 and 6, eight of 19 components (44.5%) were loose; in hips with scores of 7 or 8, 13 of 17 components (70.6%) were loose; and for hips with scores of 9 and 10, nine of nine components (100%) were loose. Receiver-operating-characteristic curve analysis demonstrated very good accuracy (area under the curve = 0.90, p < 0.001). The optimal cutoff point was a score of ≥ 5 with a sensitivity of 0.79, and a specificity of 0.87. Conclusion. There was a strong correlation between the scoring system and the probability of loosening of a cementless acetabular component. This scoring system provides a clinically useful tool for pre-operative planning, and the evaluation of the outcome of revision surgery for patients with loosening of a cementless acetabular component in the presence of osteolysis. Cite this article: Bone Joint J 2017;99-B:601–6

Introduction. Patients-reported outcome measures (PROMs) have been reported as the important methods to evaluate clinical outcomes in total knee arthroplasty (TKA). The patient satisfaction score in Knee Society Score (KSS-2011) has been used in the recent literatures. Patient satisfaction was subjective parameter, and would be affected by multiple factors including psychological factors and physical conditions at not only affected joint but also elsewhere in the body. The question was raised regarding the consistency of patient satisfaction score in KSS-2011 to other PROMs. The purpose of this study was to investigate the correlation of patient satisfaction in KSS-2011 to other categories in KSS-2011 and to other PROMs including Forgotten Joint Score (FJS-12), EuroQol-5 Dimensions (EQ-5D) and 25-questions in Geriatric Locomotive Function Scale (GLFS-25). Material & Method. 83 patients over 65 years old with osteoarthritic knees were involved in this study. All patients underwent CR-TKAs (Persona CR. R. ). The means and ranges of demographics were as follows: age; 74.5 years old (65–89), Hip-Knee-Ankle (HKA) angle; 12.4 (−6.2–22.5) in varus. We asked patients to fulfill the questionnaire including KSS-2011, FJS-12, EQ-5D and GLFS-25 at 1-year postoperative follow-up visit. KSS-2011 consisted of 4 categories of questions; patient satisfaction (PS), symptoms, patient expectations (PE), functional activities (FA). We evaluated the correlation of PS to other PROMs using simple linear regression analyses (p<0.001). Results. The means and standard deviations of 1-year postoperative scores were as follows: PS; 28.5 ± 7.0, symptoms; 19.1 ± 4.3, PE; 11.2 ± 2.9, FA; 71.5 ± 16.6, FJS-12; 51.5 ± 18.6, EQ5D; 0.69 ± 0.10, GLFS-25; 25.7 ± 16.9. PSs were moderately positively correlated to other categories in KSS-2011(correlation coefficient (r): symptoms; 0.69, PE; 0.73, FA; 0.69). PSs were positively correlated to both FJS-12 and EQ5D (r: FJS-12; 0.72, EQ-5D; 0.67) and negatively correlated to GLFS-25(r; −0.74). Discussions. Patient satisfaction score positively correlated to the symptoms, patient expectation and functional activities in KSS-2011 with moderately high correlation coefficient. This meant the better pain relief and functional outcome improved patient satisfaction. Although there had be reported preoperative higher expectation would lead to poor patient satisfaction postoperatively, we interestingly found positive correlation between patient satisfaction and expectation at 1 year after TKA. Patient with the higher satisfaction tended to expect more in the future, on the other hand, unsatisfied patient with residual pain and/or poor function would resign themselves to the present status and reduced their expectation in our patient population. We have found patient satisfaction score in KSS-2011 significantly correlated to FJS-12 and GLFS-25 with strong correlation coefficient. This meant patient satisfaction could be considered consist to other PROMS in relatively younger patient with better functional status in this study. Conclusion. The patient satisfaction score in KSS-2011 was found to be consistent with moderately high correlations coefficient to other categories in KSS-2011 and other PROMs including FJS-12, EQ-5D, GLFS-25 at 1 year after (CR)-TKA. For any figures or tables, please contact authors directly

Purpose. With growing attention being paid to quality and cost effectiveness in healthcare, outcome evaluations are becoming increasingly important. This determination can be especially difficult in reverse shoulder arthroplasty (RSA) given the complex pathology and extensive disabilities in this patient population. Several different scoring systems have been developed and validated for use in various shoulder pathologies. The purpose of this study was to assess the use three outcome scores in a population of patients undergoing RSA. We aim to demonstrate the validity of three outcome scores in patients undergoing RSA, and to determine if one score or a combination of scores is superior to others. Methods. Using a database of patients treated with RSA, we assessed preoperative and postoperative Constant Scores, American Shoulder and Elbow Surgeons (ASES) scores, and subjective shoulder values (SSV) in 148 shoulders. The outcomes at each scoring period were described and the scores were compared to one another as well as to active range of motion using linear regression modeling. Results. There were no significant differences in the mean improvement of any of the scores. All of the outcome scales improvements were correlated with each other and improvement in forward elevation but not with external rotation. Using multivariate regression analysis all 3 outcome measures were able to predict 38.9% of the variation in improvement in functional outcomes (forward elevation). This was only slightly greater than that provided by improvements in the outcome variable CS alone (36.7%). Conclusion. The three shoulder outcome scores evaluated, regardless of whether they were patient reported or physician based, appear to appropriately reflect improvements after RSA with equal validity. The objective physician assessed Constant score had the strongest correlation with function of the arm, and use of a combination of all 3 outcome scores does not increase the ability to predict range of motion compared to using the Constant Score alone

Aims. The aim of this study was to determine if the Oxford Knee and Hip Score (OKHS) can accurately predict when a primary knee or hip referral is deemed nonsurgical versus surgical by the surgeon during their first consultation, and to identify nonsurgical OKHS screening thresholds. Patients and Methods. We retrospectively reviewed pre-consultation OKHS for all consecutive primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) consultations of a single surgeon over three years. The 1436 knees (1016 patients) and 478 hips (388 patients) included were categorized based on the surgeon’s decision into those offered surgery during the first consultation versus those not (nonsurgical). Spearman’s rank correlation coefficients and receiver operating characteristic (ROC) curve analysis were performed. Results. Oxford Scores were better for the nonsurgical cohorts (p < 0.001) and correlated with the surgical decision (p < 0.001). ROC area under the curve values for knees (0.83, 95% confidence intervals (CI) 0.81 to 0.85) and hips (0.87, 95% CI 0.84 to 0.91) were excellent. A conservative and effective threshold for knees is Oxford Knee Score (OKS) > 32 points (sensitivity = 0.997, negative predictive value (NPV) = 0.992) and for hips is Oxford Hip Score (OHS) > 34 points (sensitivity = 0.997, NPV = 0.978). Severable potential lower OKHS thresholds were identified. Conclusion. Pre-consultation OKHS demonstrate good ability to predict when a primary TKA or THA referral will be deemed nonsurgical in a single surgeon’s practice. Multiple OKHS thresholds can effectively screen out nonsurgical referrals. Cite this article: Bone Joint J 2019;101-B(6 Supple B):23–30

Background. The Nottingham Hip Fracture Score (NHFS) is a risk stratifying score that estimates the 30-day and 12-month mortality rates of hip fracture patients. To date, it has only been validated in few centres in the UK. Our study aims to see how our mortality rates compare with those predicted by the NHFS. Methods. The Nottingham Hip Fracture Database was reviewed for patients presenting to our unit from August 2012 - March 2013 with a neck of femur fracture. Patient information was obtained from the database and our online electronic patient records for NHFS calculation. Patients with incomplete data were excluded. Results. 285 patients were identified, 11 were excluded. 69 (24%) were male. The average age was 82 years. The highest mortality was in those with a NHFS=9 (50%). The high-risk (NHFS≥5) patients had a higher mortality rate (n=19, 13%) compared to the low risk group (NHFS≤4) (n=7; 5%). Conclusions. Our study shows that most of our patients had a NHFS 4 – 6, which is comparable to other units. Mortality rates increased steeply from 5% to 16% from NHFS 5–6. A validation study of the NHFS showed that a score of greater than 6 was more closely correlated with high mortality. For NHFS=2, the mortality was 20%. The patient who died was a 48-year old female with breast cancer and 2 previous pulmonary emboli. The published co-morbidities for NHFS doesn't include PEs and may underestimate a patient's morbidity. Large-scale nationwide studies to determine the validity of the NHFS are needed. Level of Evidence. 4

Topic. Utilizing radiographic, physical exam and history findings, we developed a novel clinical score to aid in the surgical decision making process for hips with borderline/ transitional dysplastic hips. Background. Treatment of borderline acetabular dysplasia (BD) is controversial with some patients having primarily instability-based symptoms while others have impingement-based symptoms. The purpose of this study was to identify the most important patient characteristics influencing the diagnosis of instability vs. non-instability, develop a clinical score (Borderline Hip Instability Score, BHIS) to collectively characterize these factors and to externally validate BHIS in a multicenter cohort BD patients. Methods. First a retrospective cohort of 186 hips undergoing surgical treatment of BD (LCEA 20°-25°) from a single surgeon experienced in arthroscopic and open techniques was used. Multivariate analysis determined characteristics associated with presence of instability (PAO+/−hip arthroscopy) or absence of instability (isolated hip arthroscopy) based on clinical diagnosis. During the study period, 39.8% of the cohort underwent PAO. Multivariate analysis with bootstrapping was performed and results were transformed into a BHIS nomogram (higher score representing more instability). Then, BHIS was externally validated in 114 BD patients enrolled in a multicenter prospective cohort study across 10 surgeons (with varied treatment approaches from arthroscopy to open procedures). Results. The most parsimonious, best fit model included 4 variables associated with the diagnosis of instability: acetabular inclination (AI), anterior center edge angle (ACEA), maximum alpha angle, and internal rotation in 90 degrees of flexion (IRF). Sex and LCEA were not significant predictors. Mean BHIS in the population was 50.0 (instability 57.7 ±7.9; non-instability 44.8±7.3, p<0.001). BHIS demonstrated excellent predictive (discriminatory) ability with c-statistic=0.89. In Part 2, BHIS maintained excellent c-statistic=0.92 in external validation. Mean BHIS in the external cohort was 53.9 (instability 66.5±11.5; non-instability 43.0±10.8, p<0.001). Discussion. In patients with BD, key factors in diagnosing significant instability treated with PAO were AI, ACEA, maximum alpha-angle, and IRF. The BHIS score allowed for differentiation of patients with and without instability in the development and external validation cohort. For any tables or figures, please contact the authors directly

Objective. Low back pain (LBP) is a common debilitating condition with great socioeconomic impact. Identifying individuals at risk of LBP is challenging. We have shown IgG N-glycans are associated with LBP. Herewith, we used polygenic risk scores (PRS) from IgG-glycome to test predictability for LBP. Methods. Clusters of IgG-glycans were identified using weighted correlation network approach in TwinsUK (n = 4246). Genome-wide association studies were carried out for the clusters and top associated SNPs (p<5e-8) were extracted. Weighted PRS was calculated as the sum of the number of copies of effect allele from GWAS multiplied by their effect size using the UK Biobank data (n = 350000). The predictive capacity of the PRS for back pain in UK Biobank was estimated using logistic regression. Results. Multiple SNPs were found to be associated with the glycan clusters near genes known to be involved in glycosylation and the inflammatory response (e.g. ST6GAL1, B4GALT1, FUT8). A total of 175 SNPs was used to calculate weighted PRS. In UK Biobank the PRS was a statically significant, but poor, predictor of the risk of back pain (β = 0.126±0.050, p = 0.015, R. 2. = 2.6e-5). The SNPs on chromosome 14 in regulatory regions of FUT8 gene, one of the key governors of core fucosylation, were found to be significantly associated with back pain in UK Biobank (FDR-adjusted p-value < 0.05). Conclusions. These pilot data suggest that genetic component of glycosylation may be associated with the risk of LBP; however, its predictive ability is poor. Conflict of Interest: YSA is a co-owner of Maatschap PolyOmica. GL is a founder and CEO of Genos Glycoscience Research Laboratory. MBF and FMKW declare no conflict of interests. Sources of Funding: The research has been supported by the EC FP7 project PainOmics (grant agreement #602736) and conducted using the UK Biobank Resource (project # 18219)

The modified Glasgow Prognostic Score (mGPS) is a validated prognostic indicator in various carcinomas as demonstrated by several meta-analyses. The mGPS includes pre-operative CRP and albumin values to calculate a score from 0–2 that correlates with overall outcome. Scores of 2 are associated with a poorer outcome. Our aim was to assess if the mGPS is reliable as a prognostic indicator for soft tissue sarcoma (STS) patients. All patients with a STS diagnosed during years 2010–2014 were identified using our prospectively collected MSK oncology database. We performed a retrospective case note review examining demographics, preoperative blood results and outcomes (no recurrence, local recurrence, metastatic disease and death). 94 patients were included. 56% were female and 53% were over 50 years. 91% of tumours were high grade (Trojani 2/3) and 73% were >5cm. 45 patients had an mGPS score of 0, 16 were mGPS 1 and 33 were mGPS 2. On univariate analysis, an mGPS of 0 or 2 was statically significant with regards to outcome (p=0.012 and p=0.005 respectively). We have demonstrated that pre-treatment mGPS is an important factor in predicting oncological outcome. A score of 0 relates to an improved prognosis whilst a score of 2 relates to an increased risk of developing metastases and death. mGPS as a prognostic indicator was not affected by either the tumour size or grade. We believe that a pre-operative mGPS should be calculated to help predict oncological outcome and in turn influence management. Further work is being undertaken with a larger cohort

Background. The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. Purpose of Study. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics. Methods. Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis. Results. 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers. Conclusion. Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics. NO DISCLOSURES

Aim. Debridement, antibiotics and implant retention (DAIR) is a widely used treatment modality for early acute prosthetic joint infection (PJI). A preoperative risk score was previously designed for predicting DAIR failure, consisting of chronic renal failure (K), liver cirrhosis (L), index surgery (I), cemented prosthesis (C) and C-reactive protein >115mg/L (KLIC). The aim of this study was to validate the KLIC score in an external cohort. Method. We retrospectively evaluated patients with early acute PJI treated with DAIR between 2006 and 2016 in three Dutch hospitals. Early acute PJI was defined as less than 21 days of symptoms and DAIR performed within 90 days after index surgery. Failure was defined as the need for 1) second DAIR, 2) implant removal, 3) suppressive antimicrobial treatment or 4) infection-related death within 60 days after debridement. Results. A total of 386 patients were included. Failure occurred in 148 patients (38.3%). Patients with KLIC scores of ≤2, 2.5–3.5, 4–5, 5.5–6.5 and ≥7 had failure rates of 27.9%, 37.1%, 49.3%, 54.5% and 85.7% respectively (p<0.001, OR 1.33), in which one point increase in the KLIC score represents a 1.33 times higher risk of failure. The ROC curve showed an area under the curve of 0.64 (95% CI 0.59–0.69). A KLIC score higher than 6 points showed a specificity of 97.9%. Conclusions. The KLIC score is a relatively good preoperative risk score for DAIR failure in patients with early acute PJI and appears to be most useful in clinical practice for patients with low or high KLIC scores

To investigate the relationship between age and the Constant score: A formula to correct for age. Method and results Healthy volunteers from the King’s College Hospital population with no previous shoulder disease were assessed using the constant score.270 healthy shoulders were tested. The subjects’ ages ranged from 16 to 83 with a mean age of 44.3. The scores ranged from 60 to 100 with a mean score of 82.3. Pearson correlation analysis gave us a trend or slope of −0.1. Corrected score= actual score −[(age-44)( −0.1)]. Conclusion We concluded that the constant score decreases with age at a rate of one point per decade and that in order to compare subjects’ scores in a standardised way this correction should be applied

Introduction. Rationing of orthopaedic services is increasingly being used by Care Commissioning Groups (CCG) within the United Kingdom to restrict the numbers of patients being referred for Total Hip Arthroplasty (THA). In Devon, only patients with an Oxford Hip Score (OHS) less than 20 are referred on for specialist Orthopaedic Review. The aim of this study was to look at long term outcomes after THA to see if this rationing has any rational base to justify its use. Methods. Consecutive patients undergoing THA in Exeter between 1996 and 2012 had OHS' collected prospectively pre-operatively and a minimum of 4 years post-operatively. These scores were analysed looking for trends in patient related outcome scores. Results. 2341 patients had an OHS at a minimum of 4 years' post-op (mean 4.97 years, SD 0.33, range 4.0–5.5). This accounted for just under 50% of patients operated on in this period. Average improvement in OHS post THA was 19.6 points (range 0–44). 45.7% of patients undergoing THA had a pre-operative OHS of greater than the CCG threshold of 20. Patients did have a significantly better increase in post-operative OHS when their starting score was less than 20 but patients above this threshold still had a significant benefit from THA. However, patients with a pre-operative OHS less than 32 seemed to have more benefit from THA compared to those with a pre-op OHS of greater than 32. Interesting 7.8% of patients did not achieve the mean detectable change of 5 points in OHS at a minimum of 4 years' post THA. Conclusion. Rationing has been introduced in many CCG's around the country. Little of the rationing decisions have their basis in scientific fact and reasoning. Our data would suggest that 92.2% of patients undergoing THA have excellent outcomes. If rationing were to be fully patient centred all patients with an OHS less than 32 should be considered for THA

Aims. Patients with multiple myeloma (MM) develop deposits in the spine which may lead to vertebral compression fractures (VCFs). Our aim was to establish which spinopelvic parameters are associated with the greatest disability in patients with spinal myeloma and VCFs. Patients and Methods. We performed a retrospective cross-sectional review of 148 consecutive patients (87 male, 61 female) with spinal myeloma and analysed correlations between spinopelvic parameters and patient-reported outcome scores. The mean age of the patients was 65.5 years (37 to 91) and the mean number of vertebrae involved was 3.7 (1 to 15). Results. The thoracolumbar region was most commonly affected (109 patients, 73.6%), and was the site of most posterior vertebral wall defects (47 patients, 31.8%). Poorer Oswestry Disability Index scores correlated with an increased sagittal vertical axis (p = 0.006), an increased number of VCFs (p = 0.035) and sternal involvement (p = 0.012). Poorer EuroQol visual analogue scale scores correlated with posterior vertebral wall defects in the thoracolumbar region (p = 0.012). The sagittal vertical axis increased with the number of fractures and kyphosis in the thoracolumbar (p = 0.009) and lumbar (p < 0.001) regions. Conclusions. In MM, patients with VCFs have poorer clinical scores at presentation in the presence of sagittal imbalance. Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis. Patients with MM should be screened for spinal lesions early. Cite this article: Bone Joint J 2016;98-B:1234–9

Background. Patient satisfaction after total knee arthroplasty (TKA) has been lower than after a similar procedure, total hip arthroplasty. Poor subjective outcomes after TKA may be partially explained by abnormal kinematics patterns after TKA. The purpose of this study was to analyse rotational kinematics patterns in knees that had undergone posterior stabilized (PS)-TKA, and to clarify the relationships between rotational kinematics patterns and patient satisfaction, as well as between rotational kinematics patterns and knee function. Materials & Methods. A total of 49 osteoarthritis knees after primary PS-TKA (NexGen LPS-Flex fixed bearing knee system) were included in this study; deformed valgus, severe flexion contractures, and highly unstable knees were excluded. We used a computer navigation system and measured knee kinematics after each surgery was completed. A single investigator gently applied a manual range of motion from full extension to flexion. The angle of the internal rotation of the tibia was measured automatically at 0º, 30º, 45º, 60º, and 90º, along with maximum extension and flexion. We categorized the post-operative rotational kinematics patterns for individual cases, focusing on the initial knee flexion from 0–30º. Type A corresponded to an increased internal rotation angle of the tibia during the initial knee flexion (screw home-like movement). Type B corresponded to an increased external or an unchanged rotation angle of the tibia. We examined the range of motion (ROM) at 6 months after surgery and assessed the 2011 Knee Society Score (2011 KSS) at ≥1 year following surgery. Statistical analysis. The difference between the two groups was compared using a Wilcoxon rank sum test. Analyses were performed with JMP statistical software v8.0 (SAS Institute). A p-value of <0.05 was regarded as significant. Results. The tibia exhibited an average of 5º of internal rotation at initial knee flexion. The type A kinematics pattern achieved a better ROM and functional activity score (2011 KSS) than the type B kinematics pattern. Discussion. Modern TKA implants have been designed to reproduce normal knee kinematics to achieve better patient satisfaction and knee function. However, few reports have described the relationship between the rotational kinematics patterns at initial knee flexion and patient satisfaction. In our study, the type A postoperative rotational kinematics pattern (screw home-like movement) had better ROM and functional activity score than the type B kinematics pattern. The movement toward the internal rotation of the tibia during initial knee flexion might be important in achieving better clinical results after PS-TKA

Aim. To investigate the validity of threshold values for the Oxford Hip and Knee Score (OHS and OKS) for treatment success 12 months after total knee or hip replacement. Methods. Questionnaires were administered to patients undergoing total hip (THA) or knee (TKA) replacement before and 12 months after surgery alongside questions assessing key accepted aspects of treatment success (satisfaction, pain relief, functional improvement) to form a composite criterion of success and assessed using receiver operator characteristic (ROC) analysis. Thresholds providing maximum sensitivity and specificity for predicting treatment success were determined for the total sample and subgroups defined by pre-surgery scores. Results. Data was available for 3203 THA and 2742 TKA patients. Applying the composite treatment success criterion, 52.7% of the TKA and 65.6% of the THA sample reported a successful treatment outcome. Accuracy for predicting treatment success was high for the OHS and OKS (both areas under curve 0.87). For the OHS a threshold value of 37.5 points showed highest sensitivity and specificity in the total sample, while for the OKS the optimal threshold was 32.5 points. Depending on pre-surgery scores optimal thresholds varied between 32.5 and 38.5 for the OHS and 28.5 and 35.5 for the OKS. Conclusions. This is the first study to apply a comprehensive composite “success” anchor to the OHS and OKS in order to determine thresholds for successful treatment with total joint replacement. Compared to widely publicised postoperative satisfaction metrics, far fewer patients report success with our composite anchor

OBJECTIVES. The use of a mobile bearing has been suggested to decrease the rate of patellar complications after total knee arthroplasty (TKA). However, to resurface or retain the native patella remains debated. Few long-term results have been documented. The present retrospective study was designed to evaluate the long-term (more than 10 years) results of mobile bearing TKAs on a national scale, and to compare pain results and survivorship according to the status of the patella. The primary hypothesis of this study was that the 10 year survival rate of mobile bearing TKAs with patella resurfacing will be different from that of mobile bearing TKAs with native patella retaining. METHODS. All patients operated on between 2001 and 2004 in all participating centers for implantation of a TKA (whatever design used) were eligible for this study. Usual demographic and peri-operative items have been recorded. All patients were contacted after the 10 year follow-up for repeat clinical examination (Knee Society score (KSS), Oxford knee questionnaire). Patients who did not return were interviewed by phone call. For patients lost of follow-up, family or general practitioner was contacted to obtain relevant information about prosthesis survival. TKAs with resurfaced patella and TKAs with retained native patella were paired according to age, gender, body mass index and severity of the coronal deformation (with steps of 5°). Pain score, KSS and Oxford knee score were compared between two groups with a Student t-test at a 0.05 level of significance. Survival curve was plotted according to the actuarial technique, using the revision for mechanical reason as end-point. The influence of the patella status was assessed with a logrank test at a 0.05 level of significance. RESULTS. 1,604 TKAs were implanted during the study time-frame. 849 cases could be paired according to age, gender, BMI and severity of the pre-operative coronal deformation (2/1 ratio) into two groups: resurfaced patella (496 cases) and retained patella (243 cases). There was no difference in any baseline criteria between both groups. 150 patients deceased before the 10 year follow up (18%). Final follow-up was obtained for 489 cases (58%). 31 reoperations (prosthesis exchange or patellofemoral revision) were performed during the study time frame (4%), with 17 reoperations for mechanical reasons (3%). KSS and Oxford knee score were significantly higher for TKAs without patella resurfacing, there was a significant difference between the 13 year survival rates of TKAs with resurfaced patella (97%) and TKAs with retained native patella (93%). CONCLUSIONS. The primary hypothesis was confirmed: 10 year survival rate of mobile bearing TKAs with patella resurfacing was better than mobile bearing TKAs with native patella retaining. Patella resurfacing may lead to a better survival after mobile bearing TKA. However, the clinical results were better after patella resurfacing when the index TKA was not revised

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead

The aim of this study was to determine whether the high-sensitivity modified Glasgow prognostic score (Hs-mGPS) could predict the disease-specific survival and oncological outcome in adult patients with non-metastatic soft-tissue sarcoma before treatment. A total of 139 patients treated between 2001 and 2012 were retrospectively reviewed. The Hs-mGPS varied between 0 and 2. Patients with a score of 2 had a poorer disease-specific survival than patients with a score of 0 (p < 0.001). The estimated five-year rate of disease-specific survival for those with a score of 2 was 0%, compared with 85.4% (95% CI 77.3 to 93.5) for those with a score of 0. Those with a score of 2 also had a poorer disease-specific survival than those with a score of 1 (75.3%, 95% CI 55.8 to 94.8; p < 0.001). Patients with a score of 2 also had a poorer event-free rate than those with a score of 0 (p < 0.001). Those with a score of 2 also had a poorer event-free survival than did those with a score of 1 (p = 0.03). A multivariate analysis showed that the Hs-mGPS remained an independent predictor of survival and recurrence. The Hs-mGPS could be a useful prognostic marker in patients with a soft-tissue sarcoma. Cite this article: Bone Joint J 2015; 97-B:847–52

To validate the Modified Forgotten Joint Score (MFJS) as a new patient-reported outcome measure (PROM) in hip and knee arthroplasty against the UK's gold standard Oxford Hip and Knee Scores (OHS/OKS). The original Forgotten Joint Score was created by Behrend et al to assess post-op hip/knee arthroplasty patients. It is a new assessment tool devised to provide a greater discriminatory power, particularly in the well performing patients. It measures an appealing concept; the ability of a patient to forget about their artificial joint in everyday life. The original FJS was a 12-item questionnaire, which we have modified to 10-items to improve reliability and missing data. Postal questionnaires were sent out to 400 total hip/knee replacement (THR/TKR) patients who were 1–2 years post-op, along with the OHS/OKS and a visual pain analog score. The data collected from the 212 returned questionnaires (53% return rate) was analysed in relation to construct and content validity. A sub-cohort of 77 patients took part in a test-retest repeatability study to assess reliability of the MFJS. The MFJS proved to have an increased discriminatory power in high-performing patients in comparison to the OHS and OKS, highlighted by its more normal frequency of distribution and reduced ceiling effects in the MFJS. 30.8% of patients (n=131) scored 42–48 (equivalent to 87.5–100 in the MFJS) or more in the OKS compared to just 7.69% in the MFJS TKR patients. The MFJS proved to have an increased test-retest repeatability based upon its intra-class correlation coefficient of 0.968 compared to the Oxford's 0.845. The MFJS provides a more sensitive tool in the assessment of well performing hip and knee arthroplasties in comparison to the OHS/OKS. The MFJS tests the concept of awareness of a prosthetic joint, rather than pain and function and therefore should be used as adjunct to the OKS/OHS

We have used the Oxford hip score to monitor the progress of 1908 primary and 279 revision hip replacements undertaken since the start of 1995. Our review programme began in early 1999 and has generated 3900 assessments. The mean pre-operative scores for primary and revision cases were 40.95 and 40.11, respectively. The mean annual score for primary replacement at between 12 and 84 months ranged between 20.60 and 22.57. A comparison of cross-sectional and longitudinal data showed no significant differences. All post-operative reviews showed a significant improvement (p ≤ 0.0001). The 50- to 60-year-old group scored significantly better than the patients over 80 years of age up to 48 months (p < 0.01). A subgroup of 826 National Health Service (NHS) and 397 private patients, treated by the senior author (2292 Oxford assessments), had a higher (i.e. worse) mean pre-operative score for the NHS patients (p ≤ 0.001). The private patients scored better than the NHS group up to 84 months (p < 0.05). Patients treated by a surgeon performing more than 100 replacements each year had a significantly better outcome up to five years than those operated on by surgeons performing fewer than 20 replacements each year. The age of the patients at the time of operation, and their pre-operative level of disability, have both been identified as affecting the long-term outcome. Awareness of the influence of these factors should assist surgeons to provide balanced advice

Increasing emphasis is placed on outcomes research. In this community study knee outcomes scores were evaluated in a ‘normal’ elderly population. The American knee society (AKS), Oxford, and Bristol knee scores were recorded in 100 elderly people without a history of lower limb disorder. The mean age of subjects was 72 years. Mean normalised scores were 90%, 91% and 94% for AKS, Oxford and Bristol knee scores respectively. There were significant negative correlations between knee score and advanced age (p< 0.001) and knee score and co-existent major medical disorders (p< 0.001). The function component was the score component most senitive to these variables (p< 0.001). Control studies are necessary if knee scores are to be taken as accurate measures of outcome. Comparison of outcome after knee replacement on the basis of knee scores should take account of demographic variables. Scores with a large ‘function’ component appear to be more susceptible to demographic variation

We investigated the long-term changes in the Harris Hip and Knee Society scores (HSS and KSS) to determine whether they result from overall functional decline rather than actual changes in the condition of the prosthesis. The HHS for 106 total hip arthroplasties with a minimum follow-up of ten years, no medical complications after operation and no evidence of radiological loosening, and the KSS for 264 total knee arthroplasties with a minimum follow-up of 12 years and no medical complications after operation or signs of radiographical loosening were evaluated. There were statistically significant drops in the functional scoring components of the joint evaluation systems despite no loosening of the prostheses or other significant medical complications. The HHS declined at an average of 0.67 points per year from between three and ten years after operation (p < 0.0001). Contributing to this were deterioration in gait and limp (p < 0.0004), the use of support aids (p < 0.0001), the distance walked (p < 0.0001) and the ability to climb stairs (p < 0.0455). The functional component of the KSS declined significantly at an average 0.88 points per year betwen the third and 12th years (p < 0.0001). There were significant declines in every component of the functional score including the distance walked (p < 0.0001), the ability to climb stairs (p < 0.0001) and the use of support aids (p < 0.0001). The knee score component of the KSS did not decline significantly (p < 0.9750). The combination of functional and pain scores within the HHS system leads to an inaccurate decline in the entire score. The decline of HHS and Knee Society functional scores in total joint arthroplasties, in the absence of implant-related problems, suggests that deterioration in the functional capacity of ageing patients is an important factor in longitudinal studies using these scoring systems

A multicenter retrospective analysis of patients treated for tibial fracture was conducted to develop a score that correlates with fracture healing time and, ultimately, to identify the risk gradient of delayed healing. The clinical records of 93 patients treated for tibial fracture at three orthopaedic centers were evaluated. Patients were considered healed when full weight bearing was allowed and no further controls were scheduled. For the purpose of our analysis, we separated patients healed within or after 180 days. Patient's risk factors known to be associated to delay healing, as well as fracture morphology and orthopaedic treatment were recorded in an electronic Case Report Form (e-CRF). Information available in the literature was used to weight the relative risk (RR) associated to each risk factor; values were combined to calculate a score to be correlated to the fracture healing time: L-ARRCO (Literature-Algoritmo Rischio Ritardo Consolidazione Ossea). Among all information collected in e-CRFs, we identified other risk factors, associated to delayed healing, that were used to calculate a new score: ARRCO. Univariate logistic analysis was used to determine a correlation between the score and healing time. Analysis by receiver operating characteristic (ROC) and calculation of the area under the curve (AUC) were used for sensitivity and specificity. Complete information was available for 53 patients. The mean value of the L-ARRCO score among patients healed within 180 days was 5.78 ± 1.59 and 7.05 ± 2.46 among those healed afterwards, p=0.044. The mean value of the ARRCO score of patients healed within 180 days was 5.92 ± 1.78 and 9.03 ± 2.79 among those healed afterwards, p<0.0001. The ROC curve shows an AUC of 0.62±0.09 for L-ARRCO and an AUC of 0.82±0.07 for ARRCO, (p<0.0001). We have shown that the ARRCO score value is significantly correlated to fracture healing time. The score may be used to identify fractures at risk of delayed healing, thus allowing surgeon's early intervention to stimulate osteogenesis

To validate the Modified Forgotten Joint Score (MFJS) as a new patient-reported outcome measure (PROM) in hip and knee arthroplasty (THR/TKR) against the UK's gold standard Oxford Hip and Knee Scores (OHS/OKS). The MFJS is a new assessment tool devised to provide a greater discriminatory power, particularly in well performing patients. It measures an appealing concept; the ability of a patient to forget about their artificial joint in everyday life. Postal questionnaires were sent out to 400 THR and TKR patients who were 1–2 years post-op. The data collected from the 212 returned questionnaires was analysed in relation to construct and content validity. 77 patients took part in a test-retest repeatability assessment. The MFJS proved to have an increased discriminatory power in high-performing patients in comparison to the OHS and OKS, highlighted by its more normal frequency of distribution and reduced ceiling effects. 30.8% of patients (n=131) achieved excellent OHS/OKS scores of 42–48 this compared to just 7.69% of patients who achieved a proportionately equivalent MFJS score of 87.5–100. The MFJS proved to have an increased test-retest repeatability based upon its intra-class correlation coefficient of 0.97 compared to the Oxford's 0.85. The MFJS provides a more sensitive tool in the assessment of well performing hip and knee arthroplasties in comparison to the OHS/OKS. The MFJS tests the concept of awareness of a prosthetic joint, rather than pain and function and therefore should be used as adjunct to the OKS/OHS

Health fund providers often require objective motivation for surgery, and patients often try to pressurise surgeons into operating. The author developed a scoring system to weigh up objectively the indications and contraindications for and urgency of joint replacement. A considerably expanded Harris Hip Score and American Knee Society ratings are used. Rather than using a subjective adjective to evaluate pain, it is objectively evaluated by type and frequency of analgesic. The totality of the patient’s condition is considered in assessing functional ability, particularly with regard to other affected joints and the patient’s ability to perform normal activities of daily living. Taken into account is how much walking, climbing and stair-climbing a patient’s work demands and whether getting to work requires a long walk or use of public transport. The functional demands of daily home life are assessed, and also how much assistance is available to the patient. By adding the American scores to the additional scores for pain and functional ability, and then subtracting that total from the functional demand, one arrives at a score for the degree of compromise. The scoring includes a prediction of the risk of morbidity and mortality. When this risk is balanced by the degree of compromise, one arrives at a score for contraindication. Put another way, pain + functional ability - functional demand =compromise, and compromise x risk of mortality and morbidity =100

Health fund providers often require objective motivation for surgery, and patients often try to pressurise surgeons into operating. The author developed a scoring system to weigh up objectively the indications and contra-indications for and urgency of joint replacement. A considerably expanded Harris Hip Score and American Knee Society ratings are used. Rather than using a subjective adjective to evaluate pain, it is objectively evaluated by type and frequency of analgesic. The totality of the patient’s condition is considered in assessing functional ability, particularly with regard to other affected joints and the patient’s ability to perform normal activities of daily living. Taken into account is how much walking, climbing and stair-climbing a patient’s work demands and whether getting to work requires a long walk or use of public transport. The functional demands of daily home life are assessed, and also how much assistance is available to the patient. By adding the American scores to the additional scores for pain and functional ability, and then subtracting that total from the functional demand, one arrives at a score for the degree of compromise. The scoring includes a prediction of the risk of morbidity and mortality. When this risk is balanced by the degree of compromise, one arrives at a score for contra-indication. Put another way, pain + functional ability – functional demand = compromise, and compromise x risk of mortality and morbidity = contraindication

INTRODUCTION. There are many factors which contribute to function after TKA. In this study we focus on the effect of varus-valgus (VV) balancing measured externally. A loose knee can show instability (Sharkey 2014) while too tight, flexion can be limited. Equal lateral-medial balancing at surgery leads to a better result (Unitt 2008; Gustke 2014), which is generally the surgical goal. Indeed similar varus and valgus laxity angles have been found in most studies in vitro (Markolf 2015; Boguszewski 2015) and in vivo (Schultz 2007; Clarke 2016; Heesterbeek 2008). The angular ranges have been 3–5 degrees at 10–15 Nm of knee moment, females having the higher angles. The goal of this study was to measure the varus and valgus laxity, as well as the functional outcome scores, of two cohorts; well-functioning total knees after at least one year follow-up, and subjects with healthy knees in a similar age group to the TKR's. Our hypothesis was that the results will be equal in the two groups. METHODS & MATERIALS. 50 normal subjects average age 66 (27 male, 23 female) and 50 TKA at 1 year follow-up minimum average age 68 years (16 male, 34 female) were recruited in this IRB study. The TKA's were performed by one surgeon (PAM) of one TKA design, balancing by gap equalization. Subjects completed a KSS evaluation form to determine functional, objective, and satisfaction scores. Varus and valgus measurements were made using the Smart Knee Fixture (Figure 1)(Borukhov 2016) at 20 deg flexion with a moment of 10 Nm. RESULTS. The statistical results are summarized in table 1. There was no significant difference in either varus or valgus laxity between the two groups (p= 0.9, 0.3 respectively). Pearson's correlation coefficient between varus and valgus laxity of the healthy group was 0.42, while for the TKA group was 0.55. In both cohorts varus laxity was significant higher than valgus laxity (p= 0.001 for healthy subjects and p=0.0001 for TKA). The healthy group had higher functional and objective KSS scores (p= 0.005, and p=0.004 respectively), but the same satisfaction scores as the TKA (p=0.3) (Table 2). No correlation was found between the total laxity of the TKA group and the KSS scores (functional, objective and satisfaction). Total laxity in females was significantly higher than in males in the healthy group, but no differences was found in the TKA group. DISCUSSION. The hypothesis of equal varus and valgus angles in the 2 groups was supported. The larger varus angle implied a less stiff lateral collateral compared with the medial collateral. If the TKA's were balanced equally at surgery, it is possible there was ligament remodeling over time. However the functional scores were inferior for the TKA compared with normal. This finding has not been highlighted in the literature so far. The causes could include weak musculature (Yoshida 2013), non-physiologic kinematics due to the TKA design, or the use of rigid materials in the TKA. The result presents a challenge to improve outcomes after TKA. For figures/tables, please contact authors directly.

Background. Delay in access to primary total hip (THA) arthroplasty continues to pose a substantial burden to patients and society in publicly funded healthcare systems. The majority of strategies to decrease wait times have focused on the time from surgical consult to surgery, however a large proportion of total wait time for these patients is the time from primary care referral to surgical consultation. Prioritization scoring tools and patient reported outcome measures are being used in an attempt to ration limited resources in the face of increasing demand. However, to our knowledge, no study has investigated whether a referral Oxford Hip Score (OHS) could be used to triage non-surgical referrals appropriately, in an effort to increase timely access to specialists for patients that are candidates for total joint replacement (TJR). Purpose. 1) To determine if a referral OHS has the predictive ability to discriminate when a hip patient will be deemed surgical versus conservative by the surgeon during their first consultation 2) To identify an OHS cut-off point that can be used to accurately predict when a primary THA referral will be deemed conservative by the consultant surgeon during the first consultation. Methods. We retrospectively reviewed all consecutive THA consultations from a single surgeon's tertiary, high volume practice over a 3-year period. Patients with a pre-consultation OHS, BMI <41, and no absolute contraindication to TJR were included. Consultation were categorized into two groups based on surgeon's decision, those that were offered THR during their first consultation (operative) versus those that were not (conservative). Baseline demographic data and OHS were abstracted. Variables of interest were compared between cohorts using the exact chi-square test and Wilcoxon rank-sum test. Spearman's rank correlation coefficients were used to measure association between pre-consult OHS and the surgeon's decision. A receiver operator characteristic (ROC) curve analysis was used to calculate the area under the curve (AUC) and to identify a cut-off point for the pre-operative OHS that identified whether or not a referral was deemed conservative. Results. The study 478 hips (388 patients) with a median OHS of 22 (IQR 16–29). Median pre-consultation OHS demonstrated clinically and statistically significant differences between the surgical versus conservative cohorts (p<0.001). Spearman's rank correlation coefficient between OHS and a patient being deemed surgical or conservative was strong for the OHS at −0.62 (95% CI −0.67 to −0.56). The ROC AUC values for hip consults (0.87, 95% CI 0.84–0.91) was good, indicating that pre-consult OHS has predictive ability to discriminate a surgeon's decision of surgical versus conservative. One plausible conservative threshold that optimized sensitivity and NPV for hips is OHS >34 (sensitivity=0.997 NPV=0.978). ROC analysis identified severable potential lower, depending on weight of prioritization of sensitivity, specificity, and NPV. Conclusion. Referral OHS demonstrate good ability to discriminate when a knee or hip TJR referral will be deemed non-surgical versus surgical at their first consultation in a single surgeon's practice. Multiple potential OHS thresholds can be applied as a tool to decrease wait times for primary THR. However, a cost analysis would aid in identifying the optimal cut-off score, and these findings need to be validated with multi-surgeon/center studies before they can be broadly applied