Objectives. Advanced glycation end-products (AGEs) are a post-translational modification of collagen that form spontaneously in the skeletal matrix due to the presence of reducing sugars, such as glucose. The accumulation of AGEs leads to collagen cross-linking, which adversely affects bone quality and has been shown to play a major role in fracture risk. Thus, intervening in the formation and accumulation of AGEs may be a viable means of protecting bone quality. Methods. An in vitro model was used to examine the efficacy of two AGE-inhibitors, aminoguanidine (AG) and pyridoxamine (PM), on ageing human cortical bone. Mid-diaphyseal tibial cortical bone segments were obtained from female cadavers (n = 20, age range: 57 years to 97 years) and randomly subjected to one of four treatments: control; glucose only; glucose and AG; or glucose and PM. Following treatment, each specimen underwent mechanical testing under physiological conditions via reference point indentation, and AGEs were quantified by fluorescence. Results. Treatment with AG and PM showed a significant decrease in AGE content versus control groups, as well as a significant decrease in the change in indentation distance, a reliable parameter for analyzing bone strength, via two-way analysis of variance (ANOVA) (p < 0.05). Conclusions. The data suggest that AG and PM prevent AGE formation and subsequent biomechanical degradation in vitro. Modulation of AGEs may help to identify novel therapeutic targets to mitigate bone quality deterioration, especially deterioration due to ageing and in AGE-susceptible populations (e.g. diabetics). Cite this article: O. Abar, S. Dharmar, S. Y. Tang. The effect of aminoguanidine (AG) and pyridoxamine (PM) on ageing human cortical bone. Bone Joint Res 2018;7:105–110. DOI: 10.1302/2046-3758.71.BJR-2017-0135.R1

Objectives. Platelet-rich plasma (PRP) is being used increasingly often in the clinical setting to treat tendon-related pathologies. Yet the optimal PRP preparations to promote tendon healing in different patient populations are poorly defined. Here, we sought to determine whether increasing the concentration of platelet-derived proteins within a derivative of PRP, platelet lysate (PL), enhances tenocyte proliferation and migration in vitro, and whether the mitogenic properties of PL change with donor age. Methods. Concentrated PLs from both young (< 50 years) and aged (> 50 years) donors were prepared by exposing pooled PRP to a series of freeze-thaw cycles followed by dilution in plasma, and the levels of several platelet-derived proteins were measured using multiplex immunoassay technology. Human tenocytes were cultured with PLs to simulate a clinically relevant PRP treatment range, and cell growth and migration were assessed using DNA quantitation and gap closure assays, respectively. Results. Platelet-derived protein levels increased alongside higher PL concentrations, and PLs from both age groups improved tenocyte proliferation relative to control conditions. However, PLs from aged donors yielded a dose-response relationship in tenocyte behaviour, with higher PL concentrations resulting in increased tenocyte proliferation and migration. Conversely, no significant differences in tenocyte behaviour were detected when increasing the concentration of PLs from younger donors. Conclusion. Higher PL concentrations, when prepared from the PRP of aged but not young donors, were more effective than lower PL concentrations at promoting tenocyte proliferation and migration in vitro. Cite this article: D. R. Berger, C. J. Centeno, N. J. Steinmetz. Platelet lysates from aged donors promote human tenocyte proliferation and migration in a concentration-dependent manner. Bone Joint Res 2019;8:32–40. DOI: 10.1302/2046-3758.81.BJR-2018-0164.R1

Aims. Patients with an acute Achilles tendon rupture (ATR) take a long time to heal, have a high incidence of deep vein thrombosis (DVT) and widely variable functional outcomes. This variation in outcome may be explained by a lack of knowledge of adverse factors, and a subsequent shortage of appropriate interventions. . Patients and Methods. A total of 111 patients (95 men, 16 women; mean age 40.3, standard deviation 8.4) with an acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Predictors of ACOS included treatment; gender; age; smoking; body mass index; time to surgery; physical activity level pre- and post-injury; symptoms; quality of life and incidence of DVT. . Results. There were three independent variables that correlated significantly with the dichotomised outcome score (ACOS), while there was no correlation with other factors. An age of less than 40 years old was the strongest independent predictor of a good outcome one year after ATR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08 to 0.51), followed by female gender (OR) 4.18, 95% CI 1.01 to 17.24). Notably, patients who did not have a DVT while immobilised post-operatively had a better outcome (OR 0.31, 95% CI 0.12 to 0.80). . Conclusion. Over the age of 40 years, male gender and having a DVT while immobilised are independent negative predictors of outcome in patients with an acute ATR. . Cite this article: Bone Joint J 2016;98-B:1635–41

Aims. Spinopelvic pathology increases the risk for instability following total hip arthroplasty (THA), yet few studies have evaluated how pathology varies with age or sex. The aims of this study were: 1) to report differences in spinopelvic parameters with advancing age and between the sexes; and 2) to determine variation in the prevalence of THA instability risk factors with advancing age. Methods. A multicentre database with preoperative imaging for 15,830 THA patients was reviewed. Spinopelvic parameter measurements were made by experienced engineers, including anterior pelvic plane tilt (APPT), spinopelvic tilt (SPT), sacral slope (SS), lumbar lordosis (LL), and pelvic incidence (PI). Lumbar flexion (LF), sagittal spinal deformity, and hip user index (HUI) were calculated using parameter measurements. Results. With advancing age, patients demonstrate increased posterior APPT, decreased standing LL, decreased LF, higher pelvic incidence minus lumbar lordosis (PI-LL) mismatch, higher prevalence of abnormal spinopelvic mobility, and higher HUI percentage. With each decade, APPT progressed posteriorly 2.1°, LF declined 6.0°, PI-LL mismatch increased 2.9°, and spinopelvic mobility increased 3.8°. Significant differences were found between the sexes for APPT, SPT, SS, LL, and LF, but were not felt to be clinically relevant. Conclusion. With advancing age, spinopelvic biomechanics demonstrate decreased spinal mobility and increased pelvic/hip mobility. Surgeons should consider the higher prevalence of instability risk factors in elderly patients and anticipate changes evolving in spinopelvic biomechanics for young patients. Cite this article: Bone Joint J 2024;106-B(8):792–801

Abstract. High tibial osteotomy (HTO) is a well-recognised procedure to address medial compartment osteoarthritis (OA). There remains dispute on the impact of pre-operative patient factors on patient related outcome measures (PROMS). Does BMI and age affect > 2 year and > 5 year oxford knee scores (OKS) and Knee injury and osteoarthritis outcome scores (KOOS). A retrospective review of a prospectively collected database was performed. Timeframe was 26/6/2014 and 25/8/2022. BMI and age were recorded. OKS and KOOS were collected at > 2 years and > 5 years. There were 81 procedures included, of these 50 had OKS and KOOS scores at > 2 years and 35 at > 5 years. Median BMI was 28.5kg/m. 2. , range was 18.6–40.8kg/m. 2. Spearman's rank for >2 year OKS was p(df)=−0.210 p=0.157, > 5 year OKS p(df)=−0.215 p=0.230. For > 2 year and > 5 year KOOS subscales there were no statistically significant associations on Spearman's rank. For age, median age was 52.5, range 26–71 years old. OKS at >2 year p(df)=0.068 p=0.664, OKS >5 years p(df)=0.065 p= 0.709. For >2 year and > 5 year KOOS subscales there were no statistically significant associations on Spearman's rank. There were no adverse outcome in patients up-to the age of 71. There were no statistically significant Spearman's rank correlations between PROMS and OKS/KOOS scores. This supports recent KOG consensus statement highlighting physiological age importance vs chronological age. Of note there were more negative associations in the BMI group compared with age

Intervertebral disc (IVD) degeneration occurs with aging, leading to low back pain (LBP), which is one of the leading conditions of disability worldwide. With the lack of effective treatment, decellularized extracellular matrix (dECM) – based biomaterials have been proposed for IVD regeneration. However, the impact of donor ages on tissue repair had never been explored before in the disc field. Therefore, we aimed to address this question. For that, a decellularization protocol for bovine nucleus pulposus (NP) of different aged donors (fetus, young and old) was optimized by testing several detergents (SDS and Triton). The process efficiency was evaluated in terms of DNA and cell removal, as well as ECM preservation. Afterwards, dECMs were repopulated with bovine NP cells and cultured ex vivo. At day 7, cell behavior, ECM de novo synthesis and remodeling were evaluated [1]. Moreover, dECMs’ inflammatory response was assessed after in vivo CAM assay. Finally, inflammatory and angiogenic cytokines were analyzed in the conditioned media-derived from dECMs by using a cytokine array. As results, an optimal decellularization protocol (SDS 0.1%, 1h), efficient at removing cells and DNA from bovine NPs, while preserving ECM cues of native tissues, was developed. After repopulation, aggrecan increased in younger NPs, while collagen 2 decreased which may be indicative of matrix remodeling [1]. After in vivo CAM assay, fetal dECMs showed the highest inflammatory response. Finally, no statistically significant changes of cytokines were detected in the matrices, despite for a trend of higher IFN-α, IFN-γ and LIF in fetal dECMs, IL-1β in young dECMs and Decorin in old dECMs. Overall, this work uncovered the importance of tissue donor ages for tissue regenerative purpose, opening new avenues for the development of appropriate therapeutic strategies for IVD degeneration. Acknowledgments: FCT, EUROSPINE, ON Foundation

The use of mesenchymal stromal cells (MSCs) in regenerative medicine and tissue engineering is well established, given their properties of self-renewal and differentiation. However, several studies have shown that these properties diminish with age, and understanding the pathways involved are important to provide regenerative therapies in an ageing population. In this PRISMA systematic review, we investigated the effects of chronological donor ageing on the senescence of MSCs. We identified 3023 studies after searching four databases including PubMed, Web of Science, Cochrane, and Medline. Nine studies met the inclusion and exclusion criteria and were included in the final analyses. These studies showed an increase in the expression of p21, p53, p16, ROS, and NF- B with chronological age. This implies an activated DNA damage response (DDR), as well as increased levels of stress and inflammation in the MSCs of older donors. Additionally, highlighting the effects of an activated DDR in cells from older donors, a decrease in the expression of proliferative markers including Ki67, MAPK pathway elements, and Wnt/ -catenin pathway elements was observed. Furthermore, we found an increase in the levels of SA- -galactosidase, a specific marker of cellular senescence. Together, these findings support an association between chronological age and MSC senescence. The precise threshold for chronological age where the reported changes become significant is yet to be defined and should form the basis for further scientific investigations. The outcomes of this review should direct further investigations into reversing the biological effects of chronological age on the MSC senescence phenotype

Abstract. Purpose. Unicompartmental knee arthroplasty (UKA) is an effective treatment for late knee osteoarthritis (OA). However, its indications remain controversial. Young age (< 60 years) has been associated with worse outcomes. The goal of this systematic review and meta-analysis is to study the effect of age on UKA outcomes. Methods. The primary objective was to compare the UKA revision rate in young patients with that of old patients, using the age thresholds of 60 and 55 years. Secondary objectives were patient-reported outcome measures (PROMs) and implant design. PubMed, Ovid, Web of Science, Google Scholar, and Cochrane library were searched in June 2021. This review was conducted in accordance with the PRISMA guidelines (PROSPERO registration number: CRD42021248322). Results. A total of 12 observational studies with 6,448 knees were included. A mean MINORS score of 19 was assigned to the review. The mean age of patients was 64.32 years, with follow-up ranging from 0.2 to 15 years. There was no significant difference in revision rate, incident or PROMs between young and old patients in the analysis for each age threshold. Further sub-analysis adjusting for implant type in mobile- and fixed-bearing prostheses also showed similar results between those above and under 60 and 55 years. Conclusion. Young age was not associated with a higher revision rate or lower functional scores. Thus, this review provides evidence that performing UKA at a younger age (< 60 years) should not be considered suboptimal. However, this finding should be applied in context, as other confounding factors need to be explored

Obesity is a known risk factor for hip osteoarthritis. The aim of this study was to compare the incidence of obesity in Australians undergoing hip replacements (HR) for osteoarthritis to the general population. A cohort study was conducted comparing data from the Australian Bureau of Statistics and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 2017-18. Body mass index (BMI) data for patients undergoing primary total hip replacement and resurfacing for osteoarthritis were obtained from the AOANJRR. The distribution of HR patients by BMI category was compared to the general population, in age and sex sub-groups. During the study period, 32,495 primary HR were performed for osteoarthritis in Australia. Compared to the general population, there was a higher incidence of Class I, II, and III obesity in patients undergoing HR in both sexes aged 35 to 74 years old. Class III obese females and males undergoing HR were on average 6 to 7 years younger than their normal weight counterparts. Class III obese females and males aged 55-64 years old were 2.9 and 1.7 times more likely to undergo HR, respectively (p<0.001). There is a strong association between increased BMI and relative risk of undergoing HR. Similar findings have been noted in the United States of America, Canada, United Kingdom, Sweden and Spain. A New Zealand Registry study and recent meta-analysis have also found a concerning trend of Class III obese patients undergoing HR at a younger age. Obese Australians are at increased risk of undergoing HR at a younger age. A national approach to address the prevalence of obesity is needed

Aims. The aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate. Methods. This retrospective analysis identified 267 hips from 224 patients who underwent an hip resurfacing arthroplasty (HRA) from a single fellowship-trained surgeon using the direct lateral approach between 2007 and 2019. Inclusion criteria was minimum two-year follow-up, and age younger than 40 years. Patients were followed using a prospectively maintained institutional database. Results. A total of 217 hips (81%) were included for follow-up analysis at a mean of 3.8 years. Of the 23 females who underwent HRA, none were revised, and the median head size was 46 mm (compared to 50 mm for males). The most common indication for HRA was femoroacetabular impingement syndrome (n = 133), and avascular necrosis ( (n = 53). Mean postoperative HHS was 100 at two and five years. No dislocations occurred. A total of four hips (1.8%) required reoperation for resection of heterotopic ossification, removal of components for infection, and subsidence with loosening. The overall revision rate was 0.9%. Conclusion. For younger patients with higher functional expectations and increased lifetime risk for revision, HRA is an excellent bone preserving intervention carrying low complication rates, revision rates, and excellent patient outcomes without lifetime restrictions allowing these patients to return to activity and sport. Thus, in younger male patients with end-stage hip disease and higher demands, referral to a high-volume HRA surgeon should be considered. Cite this article: Bone Jt Open 2023;4(6):408–415

Aims. Current levels of hip fracture morbidity contribute greatly to the overall burden on health and social care services. Given the anticipated ageing of the population over the coming decade, there is potential for this burden to increase further, although the exact scale of impact has not been identified in contemporary literature. We therefore set out to predict the future incidence of hip fracture and help inform appropriate service provision to maintain an adequate standard of care. Methods. Historical data from the Scottish Hip Fracture Audit (2017 to 2021) were used to identify monthly incidence rates. Established time series forecasting techniques (Exponential Smoothing and Autoregressive Integrated Moving Average) were then used to predict the annual number of hip fractures from 2022 to 2029, including adjustment for predicted changes in national population demographics. Predicted differences in service-level outcomes (length of stay and discharge destination) were analyzed, including the associated financial cost of any changes. Results. Between 2017 and 2021, the number of annual hip fractures increased from 6,675 to 7,797 (15%), with a rise in incidence from 313 to 350 per 100,000 (11%) for the at-risk population. By 2029, a combined average projection forecast the annual number of hip fractures at 10,311, with an incidence rate of 463 per 100,000, representing a 32% increase from 2021. Based upon these projections, assuming discharge rates remain constant, the total overall length of hospital stay following hip fracture in Scotland will increase by 60,699 days per annum, incurring an additional cost of at least £25 million per year. Approximately five more acute hip fracture beds may be required per hospital to accommodate this increased activity. Conclusion. Projection modelling demonstrates that hip fracture burden and incidence will increase substantially by 2029, driven by an ageing population, with substantial implications for health and social care services. Cite this article: Bone Joint J 2024;106-B(1):62–68

Aims. The aim of this study was to assess factors associated with the estimated lifetime risk of revision surgery after primary knee arthroplasty (KA). Methods. All patients from the Scottish Arthroplasty Project dataset undergoing primary KA during the period 1 January 1998 to 31 December 2019 were included. The cumulative incidence function for revision and death was calculated up to 20 years. Adjusted analyses used cause-specific Cox regression modelling to determine the influence of patient factors. The lifetime risk was calculated as a percentage for patients aged between 45 and 99 years using multiple-decrement life table methodology. Results. The estimated lifetime risk of revision ranged between 32.7% (95% confidence interval (CI) 22.6 to 47.3) for patients aged 45 to 49 years and 0.6% (95% CI 0.1 to 4.5) for patients aged over 90 years. At 20 years, the overall cumulative incidence of revision (6.8% (95% CI 6.6 to 7.0)) was significantly less than that of death (66.3% (95% CI 65.4 to 67.1)). Adjusted analyses demonstrated converse effect of increasing age on risk of revision (hazard ratio (HR) 0.5 (95% CI 0.5 to 0.6)) and death (HR 3.6 (95% CI 3.4 to 3.7)). Male sex was associated with increased risks of revision (HR 1.1 (95% CI 1.1 to 1.2); p < 0.001) and death (HR 1.4 (95% CI 1.3 to 1.4); p < 0.001). Compared to patients undergoing primary KA for osteoarthritis, patients with inflammatory arthropathy had a higher risk of death (HR 1.7 (95% CI 1.7 to 1.8); p < 0.001), but were less likely to be revised (HR 0.9 (95% CI 0.7 to 1.0); p < 0.001). Patients with a greater number of comorbidities (HR 1.4 (95% CI 1.3 to 1.4)) and greater levels of socioeconomic deprivation (HR 1.4 (95% CI 1.4 to 1.5)) were at increased risk of death, but neither increased the risk of revision. Conclusion. The estimated lifetime risk of revision KA varied depending on patient sex, age, and underlying diagnosis. Patients aged between 45 and 49 years had a one in three risk of undergoing revision surgery within their lifetime, which decreased with age to one in 159 in those aged 90 years or more. Cite this article: Bone Joint J 2022;104-B(12):1313–1322

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

Intra-Discal Vacuum Phenomenon (IDVP) represents an intradiscal nitrogen gas accumulation where a cavity opens in a supine position, lowering intra-discal pressure and generating a bubble. IDVP has been observed in up to 20% of elderly patients and reported in almost 50% of chronic LBP patients. With a highly accurate detection on CT, its significance lacks clarity and consideration within normative data. IDVP occurs with patterns of lumbar and/or lumbopelvic morphology and associated diagnoses. Over-60s population based sample of 2020 unrelated CT abdomen scans without acute spinal presentations, with sagittal reconstructions, inclusive of T12 to femoral heads, were analyzed for IDVP and pelvic incidence (PI). Subjects with diagnostic morphological associations of the lumbar spine, including previous fracture, autofusion, transitional vertebra and listhesis, were selected out and analyzed separately. Subjects were then equally grouped into low, medium and high PI. Prevalence of lumbar spine IDVP is 41.3%. 125 cases were excluded. 1603 subjects yielded 663 IDVP. This was increased in severity towards the lumbosacral junction (L1L2 9.4%, L2L3 10.9%, L3L4 13.7%, L4L5 19.9%, L5S1 28.5%) and those with low PI, while distribution was more even with high PI. 292 had positive diagnostic associations, which were more likely to occur at the level of isthmic spondylolisthesis, adjacent to a previous fracture or suprajacent to lumbosacral transitional vertebra (p<0.05). This study has identified normative values for prevalence and severity of IDVP in a normal aging population. Morphological patterns that influence the pattern of IVDP such as pelvic incidence and diagnostic associations provide novel insights to the function of the aging spine

Aims. The primary aim of our study was to assess the influence of age on hip-specific outcome following total hip arthroplasty (THA). Secondary aims were to assess health-related quality of life (HRQoL) and level of activity according to age. Methods. A prospective cohort study was conducted. All patients were fitted with an Exeter stem with a 32 mm head on highly cross-linked polyethylene (X3RimFit) cemented acetabulum. Patients were recruited into three age groups: < 65 years, 65 to 74 years, and ≥ 75 years, and assessed preoperatively and at three, 12, 24, and 60 months postoperatively. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), and Hip disability and Osteoarthritis Outcome Score (HOOS), were used to assess hip-specific outcome. EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and 36-Item Short Form Survey (SF-36) scores were used to assess HRQoL. The Lower Extremity Activity Scale (LEAS) and Timed Up and Go (TUG) were used to assess level of activity. Results. There were no significant (p > 0.05) differences in the WOMAC scores, HSS, HOOS, or EQ-5D-5L at any postoperative timepoint between the age groups. Patients aged ≥ 75 years had significantly lower physical function (p ≤ 0.010) and physical role (p ≤ 0.047) SF-36 scores at 12, 24, and 60 months, but were equal to that expect of an age-matched population. No differences according to age were observed for the other six domains of the SF-36 (p > 0.060). The ≥ 75 years group had a lower LEAS (p < 0.001) and longer TUG test times (p ≤ 0.032) compared to the < 65 years group, but older age groups had significant (p < 0.001) improvement relative to their preoperative baseline measures. Conclusion. Age did not influence postoperative hip-specific outcome or HRQoL (according to the EQ-5D) following THA. Despite a significant improvement, older patients had lower postoperative activity levels compared to younger patients, but this may be reflective of the overall physical effect of ageing. Cite this article: Bone Jt Open 2022;3(9):692–700

The study of spinopelvic anatomy and movement has received great interest as these characteristics influence the biomechanical behavior (and outcome) following hip arthroplasty. However, to-date there is little knowledge of what “normal” is and how this varies with age. This study aims to determine how dynamic spino-pelvic characteristics change with age, with well-functioning hips and assess how these changes are influenced by the presence of hip arthritis. This is an IRB-approved, cross-sectional, cohort study; 100 volunteers (asymptomatic hips, Oxford-Hip-sore>45) [age:53 ± 17 (24-87) years-old; 51% female; BMI: 28 ± 5] and 200 patients with end-stage hip arthritis [age:56 ± 19 (16-89) years-old; 55% female; BMI:28 ± 5] were studied. All participants underwent lateral spino-pelvic radiographs in the standing and deep-seated positions to determine maximum hip and spine flexion. Parameters measured included lumbar-lordosis (LL), pelvic incidence, pelvic-tilt (PT), pelvic-femoral angles (PFA). Lumbar flexion (ΔLL), hip flexion (ΔPFA) and pelvic movement (ΔPT) were calculated. The prevalence of spinopelvic imbalance (PI–LL>10?) was determined. There were no differences in any of the spino-pelvic characteristics or movements between sexes. With advancing age, standing LL reduced and standing PT increased (no differences between groups). With advancing age, both hip (4%/decade) and lumbar (8%/decade) flexion reduced (p<0.001) (no difference between groups). ΔLL did not correlate with ΔPFA (rho=0.1). Hip arthritis was associated with a significantly reduced hip flexion (82 ±;22? vs. 90 ± 17?; p=0.003) and pelvic movements (1 ± 16? vs. 8 ± 16?; p=0.002) at all ages and increased prevalence of spinopelvic imbalance (OR:2.6; 95%CI: 1.2-5.7). With aging, the lumbar spine loses its lumbar lordosis and flexion to a greater extent that then the hip and resultantly, the hip's relative contribution to the overall sagittal movement increases. With hip arthritis, the reduced hip flexion and the necessary compensatory increased pelvic movement is a likely contributor to the development of hip-spine syndrome and of spino-pelvic imbalance

Osteoarthritis is a common articular cartilage disorder and causes a significant global disease burden. Articular cartilage has a limited capacity of repair and there is increasing interest in the use of cell-based therapies to facilitate repair including the use of Mesenchymal Stromal Cells (MSCs). There is some evidence in the literature that suggests that advancing age is associated with declining MSC function, including reduced proliferation and differentiation potential, and greater cellular apoptosis. In our study, we first performed a systematic review of the literature to determine the effects of chronological age on the in vitro properties of MSCs, and then performed a laboratory study to investigate these properties. We initially conducted a PRISMA systematic review of the literature to review the evidence base for the effects of chronological age on the in vitro properties of MSCs including cell numbers, expansion, cell surface characterization and differentiation potential. This was followed by laboratory based experiments to assess these properties. Tissue from patients undergoing total knee replacement surgery was used to isolate MSCs from the bone fragments using a method developed in our laboratory. The growth kinetics was determined by calculating the population doublings per day. Following expansion in culture, MSCs at P2 were characterised for a panel of cell surface markers using flow cytometry. The cells were positive for CD73, CD90 and CD105, and negative for CD34 and CD45. The differentiation potential of the MSCs was assessed through tri-lineage differentiation assays. Clear differences between the younger and older patients were indicated. Chronological age-related changes in MSC function have important implications on the use of these cells in clinical applications for an ageing population. The results from this study will be used to plan further work looking at the effects of chronological age on cellular senescence and identify pathways that could be targeted to potentially reverse any age-related changes

Abstract. Introduction. Little is known about employment following revision total knee arthroplasty (RTKA). This study aims to describe factors associated with returning to employment in patients of working age who underwent RTKA surgery. Methodology. We performed a retrospective assessment of all patients aged ≤65 who underwent RTKA at our NHS institution between 2006 and 2020. All indications and revision procedures were included. Pre-operative demographics, indication for surgery and Oxford Knee Scores (OKS) were recorded. Postal questionnaires were sent to patients including patient reported outcome measures and departmental questionnaire asking patients about employment status pre- and post-operatively. Results. 132 procedures were performed in 113 patients. Median follow up was 5.5 years (2.4–9.0). Mean age was 58 (5.8) and 50% (57) were male. 62 patients undergoing 74 procedures responded to postal questionnaires and were included in the study. 53% (33) were employed prior to surgery and 61% (38) returned to work at a median of 12 weeks (3–150). Of the 24 who did not return to work, 7 reported intending to return to work. Those patients who returned to work had increased pre-operative OKS (16.9 vs 13.6) and mean improvement (16.5 vs 12.4). Conclusion. This study is limited by small numbers and its observational nature. In this population the majority of patients who wished to return to work after RTKA were able to do so. This provides some reassurance when counselling patients. Prospective studies to better understand the factors that predict return to work will be important with increasing demands from surgery

The influence of patient age on functional outcomes after periacetabular osteotomy (PAO) for acetabular dysplasia remains unclear, with previous studies utilising scores developed for older, arthritic patients. The purpose of this study is to assess the influence of patient age on International Hip Outcome Tool (iHOT-12) scores, two years after PAO. Eighty-six patients (72 female, 14 male; mean age 26.9 years) who underwent PAO by a single surgeon and had completed a minimum of two years follow up were identified. Patients were categorised into three groups according to age at the time of surgery: adolescent (11–20 years; n=29), young adult (21–30 years; n=29), and mature (≥31 years; n=28). The three groups were compared with respect to baseline variables and functional outcomes (iHOT-12, EQ-5D quality of life score, University of California Los Angeles (UCLA) activity score, pain visual analogue score (VAS)). Multivariate regression was undertaken to assess for independent predictors of two-year iHOT-12 score. The adolescent group demonstrated a lower BMI (p=0.004) while the mature group had a greater American Society of Anaesthesiology (ASA) score (p=0.049). There were otherwise no significant differences in baseline variables between the three groups (all p>0.05). The three groups demonstrated significant post-operative improvements across all functional outcome measures. There were no significant differences in two-year iHOT-12, EQ-5D, UCLA score or pain VAS between the three groups (all p>0.05). Regression modelling found that patient age at the time of surgery did not have an independent effect on two-year iHOT-12 score (p=0.878). We found that patient age at the time of surgery did not influence functional outcomes two years after PAO. Our results suggest that patient age should not be considered in isolation as an indication or contraindication for PAO

Arthroscopic hip procedures have increased dramatically over the last decade as equipment and techniques have improved. Patients who require hip arthroscopy for femoroacetabular impingement on occasion require surgery on the contralateral hip. Previous studies have found that younger age of presentation and lower Charlson comorbidity index have higher risk for requiring surgery on the contralateral hip but have not found correlation to anatomic variables. The purpose of this study is to evaluate the factors that predispose a patient to requiring subsequent hip arthroscopy on the contralateral hip. This is an IRB-approved, single surgeon retrospective cohort study from an academic, tertiary referral centre. A chart review was conducted on 310 primary hip arthroscopy procedures from 2009-2020. We identified 62 cases that went on to have a hip arthroscopy on the contralateral side. The bilateral hip arthroscopy cohort was compared to unilateral cohort for sex, age, BMI, pre-op alpha angle and centre edge angle measured on AP pelvis XRay, femoral torsion, traction time, skin to skin time, Tonnis grade, intra-op labral or chondral defect. A p-value <0.05 was deemed significant. Of the 62 patients that required contralateral hip arthroscopy, the average age was 32.7 compared with 37.8 in the unilateral cohort (p = 0.01) and BMI was lower in the bilateral cohort (26.2) compared to the unilateral cohort (27.6) (p=0.04). The average alpha angle was 76.3. 0. in the bilateral compared to 66. 0. in the unilateral cohort (p = 0.01). Skin to skin time was longer in cases in which a contralateral surgery was performed (106.3 mins vs 86.4 mins) (p=0.01). Interestingly, 50 male patients required contralateral hip arthroscopy compared to 12 female patients (p=0.01). No other variables were statistically significant. In conclusion, this study does re-enforce existing literature by stating that younger patients are more likely to require contralateral hip arthroscopy. This may be due to the fact that these patients require increased range of motion from the hip joint to perform activities such as sports where as older patients may not need the same amount of range of motion to perform their activities. Significantly higher alpha angles were noted in patients requiring contralateral hip arthroscopy, which has not been shown in previous literature. This helps to explain that larger CAM deformities will likely require contralateral hip arthroscopy because these patients likely impinge more during simple activities of daily living. Contralateral hip arthroscopy is also more common in male patients who typically have a larger CAM deformity. In summary, this study will help to risk stratify patients who will likely require contralateral hip arthroscopy and should be a discussion point during pre-operative counseling. That offering early subsequent or simultaneous hip arthroscopy in young male patients with large CAMs should be offered when symptoms are mild

Abstract. Introduction. Meniscal repair is an accepted surgical option for meniscal tears. However, there remains trepidation with regard to offering such surgery to older patients. We aim to evaluate the outcomes in these such patients. Methodology. A single surgeons log was used to identify patients who underwent meniscal repair and were over the age of 40. Patients having concurrent anterior cruciate ligament reconstructions were excluded. Demographic data, surgical data and outcomes (pain visual analogue score (VAS); single assessment numerical evaluation (SANE) and knee injury and osteoarthritis outcome joint replacement (KOOS Jr) score) were collected prospectively. Final outcomes were collected between 6–12 months following surgery. Results. 24 meniscal tears in 22 knees (22 patients) were identified. Mean age was 52.2 (range; 40.6-70.3). Morphology of the tears were medial meniscus posterior root tear 10 (42%); medial meniscus posterior horn tear 9 (38%); lateral meniscus posterior horn tear 2 (8.3%); lateral meniscus posterior root tear 1 (4.2%); lateral meniscus body tear 1 (4.2%) and lateral meniscus anterior horn tear 1 (4.2%). Response rate was 86%. Statistically significant improvements in pain VAS (p=0.0001); SANE (p=0.0001) and KOOS Jr Score (p=0.0005) were found. 68% and 74% of patients had surpassed the MCID in their KOOS symptoms and KOOS quality of life subscales, respectively. Conclusion. Meniscal repair in patients over 40 years of age is an acceptable treatment with significant improvements in patients reported outcome measures, SANE and pain VAS

Aims. Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost. Methods. In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA. Results. Cemented fixation had the lowest implant survival in all age groups, with a total ten-year survivorship of 97.0% (95% confidence interval (CI) 95.8 to 97.8) in the cemented group, 97.6% (95% CI 96.9 to 98.1) in the hybrid group, and 97.9% (95% CI 96.9 to 98.6) in the cementless group. This was not statistically significant (p = 0.092). There was no age group where cemented fixation outperformed hybrid or cementless fixation. Conclusion. While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. We recommend that surgeons should carefully monitor their own outcomes and use fixation techniques that they are familiar with, and deliver the best outcomes in their own hands. Cite this article: Bone Joint J 2022;104-B(2):206–211

Aging impairs the regenerative capacity of musculoskeletal tissues and is associated with poor healing outcomes. PolgA. D257A/D257A. (PolgA) mice present a premature aging phenotype due to the accumulation of mitochondrial DNA (mtDNA) point mutations at rates 3 – 5 fold higher compared to wild type mice. Consequently, PolgA mice exhibit the premature onset of clinically-relevant musculoskeletal aging characteristics including frailty, osteo-sarcopenia, and kyphosis. I will present our recent findings on the use of PolgA mice to investigate the effects of aging on the regenerative capacity of bone. In particular, I will focus on the mechano-sensitivity of the regenerative process in aged bone environments and the opportunities it presents for clinical translation of mechanical intervention therapies

Introduction and Objective. Neoangiogenesis drives the replacement of mineralized cartilage by trabecular bone during bone growth regulated by molecules like e.g. VEGF, OPG and RANKL and the close interaction of progenitors of osteoblasts, chondrocytes, endothelial cells and osteoclasts/chondroclasts. The Heparan sulfate proteoglycan Syndecan-1 (Sdc-1) plays a role in the interaction between osteoclasts and osteoblasts and the development of blood vessels. As the processes of osteogenesis and angiogenesis are closely related to each other in bone, we expected Sdc-1 to have an influence on vessel structure during aging. Therefore, angiogenesis at the growth plate in mice of different ages was compared and the influence of Syndecan-1 deficiency was characterized. Materials and Methods. Animals: C57BL/6 (WT) and Sdc1−/− mice were used for native bone analysis at 4, 12 and 18 month age. Femura were dissected, cryoprotected and embedded. Histology: Embedded bones were sectioned into 80um thick slices so that the 3D network of the vascularization of the bone could be visualized using an anti-Endomucin antibody and DAPI as counter staining. For semi-automatical quantification of the vessel bulbs we used a custom made software. In vitro angiogenesis: For aortic ring assay, aortic tissue was isolated from 4 month old mice, cut into 0.5mm rings and embedded in collagen type I matrix. Microvessel outgrowth was quantified after 6 days of culture. Results. We verified our custom-made software using slices of WT mice and showed that there is no variation of the number of bulbs with regard to the width of the growth plate in periphery versus center zones in all age groups which indicates a homogeneous distribution of angiogenesis throughout the interface of cartilage to newly forming bone. Furthermore, in both, WT and Sdc-1 deficient mice the number of bulbs decreased significantly with age. However, Sdc-1 knockout mice at the age of 4 and 12 month showed a highly significant decrease in angiogenesis close to the growth plate compared to WT mice, whereas in older mice these differences were gone. Quantification of microvessel outgrowth of aortic tissue revealed a significant decrease in number of vessels from rings taken from Syndecan-1 deficient mice compared to WT mice. Conclusions. Syndecan-1 has a significant impact on neoangiogenesis in vitro and in vivo during aging as demonstrated at the chondro-osseous border of the native bone, emphasizing the importance to further characterize the function of Syndecan-1 regulated processes during enchondral ossification

Aims. This study intended to investigate the effect of vericiguat (VIT) on titanium rod osseointegration in aged rats with iron overload, and also explore the role of VIT in osteoblast and osteoclast differentiation. Methods. In this study, 60 rats were included in a titanium rod implantation model and underwent subsequent guanylate cyclase treatment. Imaging, histology, and biomechanics were used to evaluate the osseointegration of rats in each group. First, the impact of VIT on bone integration in aged rats with iron overload was investigated. Subsequently, VIT was employed to modulate the differentiation of MC3T3-E1 cells and RAW264.7 cells under conditions of iron overload. Results. Utilizing an OVX rat model, we observed significant alterations in bone mass and osseointegration due to VIT administration in aged rats with iron overload. The observed effects were concomitant with reductions in bone metabolism, oxidative stress, and inflammation. To elucidate whether these effects are associated with osteoclast and osteoblast activity, we conducted in vitro experiments using MC3T3-E1 cells and RAW264.7 cells. Our findings indicate that iron accumulation suppressed the activity of MC3T3-E1 while enhancing RAW264.7 function. Furthermore, iron overload significantly decreased oxidative stress levels; however, these detrimental effects can be mitigated by VIT treatment. Conclusion. Collectively, our data provide compelling evidence that VIT has the potential to reverse the deleterious consequences of iron overload on osseointegration and bone mass during ageing. Cite this article: Bone Joint Res 2024;13(9):427–440

Abstract. Objectives. Osteoarthritis is a common articular cartilage disorder and causes a significant global disease burden. Articular cartilage has a limited capacity of repair and there is increasing interest in the use of cell-based therapies to facilitate repair including the use of Mesenchymal Stromal Cells (MSCs). There is some evidence in the literature that suggests that advancing age and gender is associated with declining MSC function, including reduced proliferation and differentiation potential, and greater cellular apoptosis. In our study, we first performed a systematic review of the literature to determine the effects of chronological age and gender on the in vitro properties of MSCs, and then performed a laboratory study to investigate these properties. Methods and Results. We initially conducted a PRISMA systematic review of the literature to review the evidence base for the effects of chronological age and gender on the in vitro properties of MSCs including cell numbers, expansion, cell surface characterization and differentiation potential. This was followed by laboratory-based experiments to assess these properties. Compare the extent of the effect of age on MSC cell marker expression, proliferation and pathways. Tissue from patients undergoing total knee replacement surgery was used to isolate MSCs from the synovium, fat pad and bone fragments using a method developed in our laboratory. The growth kinetics was determined by calculating the population doublings per day. Following expansion in culture, MSCs at P2 were characterised for a panel of cell surface markers using flow cytometry. The cells were positive for CD73, CD90 and CD105, and negative for antibody cocktail (eg included CD34, CD45). The differentiation potential of the MSCs was assessed through tri-lineage differentiation assays. At P2 after extracting RNA, we investigate the gene analysis using Bulk seq. Clear differences between the younger and older patients and gender were indicated. Conclusions. Chronological age and gender-related changes in MSC function have important implications on the use of these cells in clinical applications for an ageing population. The results from this study will be used to plan further work looking at the effects of chronological age and gender on cellular senescence and identify pathways that could be targeted to potentially reverse any age and gender-related changes. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

There is an increasing demand worldwide for total hip arthroplasty in patients over 80 years old. This study is the largest of its kind reporting long term outcomes and clinical survivorship of patients over 80 years old undergoing THR. 13171 patients 80 years or older who underwent THR between 2000 and 2019 were included. Demographic and operative data was collected including age, sex, laterality, date of surgery and operative technique. Presence and date of complications were collected. Data was also collected for the same time period on 80910 patients aged 51–79 years undergoing THR for comparison. 4103 (31.2%) male and 9068 female (68.8%) patients were included in the 80year old cohort. Median age was 83 (IQR 81–83, range 80–98). 32682 (40.4%) male and 48227 (59.6%) females were included in the 50–79year old cohort. Median age was 68 (IQR 62–73, range 50–79). The 80 cohort was more likely to sustain post operative complications in the 6 months following surgery including DVT (81/13171 vs 364/80910, P<0.05), myocardial infarction (177/13171 vs 341/80910, P<0.05), acute renal failure (371/12800 vs 812/80910 P<0.05). The 50–79year old cohort was over twice as likely to undergo revision surgery than the 80 year old cohort (HR 2.55, 95% CI 2.216–2.932, p<0.001). Of those requiring revision surgery, the elderly cohort were more likely to undergo earlier revision surgery (378days, 95%CI 236–519d vs 1586days, 95%CI 1471–1700d, p<0.001). In those undergoing revision surgery, a higher proportion were done for infection in the 80 year old cohort (39/219 (17.8%) vs 215/2809 (7.7%), p<0.05. This study demonstrates good outcomes in terms of medical complications and a low overall risk of requiring revision surgery in patients 80years old undergoing THR. Patients over the age of 80 should be counselled on the relatively increased risk of medical complications post operatively

Hip resurfacing arthroplasty (HRA) is being offered as a viable alternative to total hip arthroplasty (THA). For very young patients (under 30 years old), THA achieves fair results but with high revision and complication rates. This retrospective study was designed to evaluate the results of HRA performed in patients under 30 years old with a long follow-up. During the inclusion period (2007–2021), we collected in a single operator database, all HRA performed in patients under 30 with a minimum follow up of 2 years. 103 HRA in 93 patients (77 male / 16 females; a mean age at operation 27.7 years (18 to 29.9)) were included. The two mean preoperative diagnoses were osteoarthritis in 54 HRA (52.5%) and DDH or hip dislocation in 19.4% (20 cases). No patient was lost to follow-up and 3 patients (5 HRA) deceased. There were 2 revisions (one for femoral aseptic loosening and one infection recurrence (pediatric osteoarthritis)). No dislocation and adverse wear-related failures were found. At a mean follow-up of 10.4 years (2–17.4), mean UCLA activity and Oxford Hip score improved respectively from 5.4 (1 to 7) and 39.9 (25–55) pre-operatively to 7.9 (3 to 10) and 15.8 (12–34) post-operatively (p<0.001). Mean Harris hip score increased from 41.6 (22–63) to 91.8 (72–100) (p<0.001). There were no radiological cases exhibiting lysis while two cases displayed limited partial radiolucency around the femoral stem. Kaplan-Meier survival analysis, with the endpoint revision for any reason, showed a 10.8-year survival rate of 98% (95% expected with NICE guidelines). This cohort of HRA performed under 30 is the longest follow-up ever reported in the literature. Despite a challenging cohort of patients, HRA exceeds the stricter NICE survivorship criteria. HRA remains an effective treatment with excellent functional outcomes and a very low rate of complications

Aims. The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears. Methods. We conducted a multicentre, open-labelled, randomized controlled trial in patients aged 18 to 45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. We performed a cost-utility analysis on the randomization groups to compare both treatments over a 24-month follow-up period. Cost utility was calculated as incremental costs per quality-adjusted life year (QALY) gained of arthroscopic partial meniscectomy compared to physical therapy. Calculations were performed from a healthcare system perspective and a societal perspective. Results. A total of 100 patients were included: 49 were randomized to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during follow-up. Over 24 months, patients in the arthroscopic partial meniscectomy group had a mean 0.005 QALYs lower quality of life (95% confidence interval -0.13 to 0.14). The cost-utility ratio was €-160,000/QALY from the healthcare perspective and €-223,372/QALY from the societal perspective, indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit. Conclusion. Arthroscopic partial meniscectomy is arthroscopic partial meniscectomy is unlikely to be cost-effective in treating young patients with isolated traumatic meniscal tears compared to physical therapy as a primary health intervention. Arthroscopic partial meniscectomy leads to a similar quality of life, but higher costs, compared to physical therapy plus optional delayed arthroscopic partial meniscectomy. Cite this article: Bone Joint J 2023;105-B(11):1177–1183

Abstract. Introduction. The number of total knee replacements (TKRs) performed continues to increase and is marked in patients under the age of 60. Increased number of younger patients raises concerns about potentially increased rates of implant failure or revision. Previous studies used small cohorts with only short to medium term follow-up. This study is the largest of its kind reporting long term outcomes and clinical survivorship of patients 50 years or less undergoing TKR. Methods. This is a retrospective cohort study using data from the Scottish Arthroplasty Project. A total of 3727 patients 50 years or less undergoing TKR between 2000 and 2019. Data was also collected for the same time period on patients aged 50–79 years undergoing TKR for comparison. Results. Mean age for under 50 years cohort at initial TKR was 45.4 years. Primary reason for TKR was osteoarthritis (3025 cases) and 321 revisions were performed. The primary reason for revision was aseptic loosening (206 cases), or infection (18 cases). Average time to revision was 5.5 years. In the 50–79 years cohort, average age was 67.5 years. Primary reason for TKR was osteoarthritis (87776 cases) and 2997 revisions were performed. Principle reason for revision was infection (256 cases), or aseptic loosening (2042 cases). Average time to revision was 4 years. Conclusion. This study suggests long-term outcome of patients aged 50 years or less undergoing TKR remain promising. Patients should be aware of relatively higher rates of aseptic loosening requiring revision in patients aged 50 years or less undergoing TKR

Aims. The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV. Methods. The consensus process followed an established Delphi approach with a predetermined degree of agreement. The process included the following steps: establishing a steering group; steering group meetings, generating statements, and checking them against the literature; a two-round Delphi survey; and final consensus meeting. The steering group members and Delphi survey participants were all British Society of Children’s Orthopaedic Surgery (BSCOS) members. Descriptive statistics were used for analysis of the Delphi survey results. The Appraisal of Guidelines for Research & Evaluation checklist was followed for reporting of the results. Results. The BSCOS-selected steering group, the steering group meetings, the Delphi survey, and the final consensus meeting all followed the pre-agreed protocol. A total of 153/243 members voted in round 1 Delphi (63%) and 132 voted in round 2 (86%). Out of 61 statements presented to round 1 Delphi, 43 reached ‘consensus in’, no statements reached ‘consensus out’, and 18 reached ‘no consensus’. Four statements were deleted and one new statement added following suggestions from round 1. Out of 15 statements presented to round 2, 12 reached ‘consensus in’, no statements reached ‘consensus out’, and three reached ‘no consensus’ and were discussed and included following the final consensus meeting. Two statements were combined for simplicity. The final consensus document includes 57 statements allocated into six successive stages. Conclusion. We have produced a consensus document for the treatment of idiopathic CTEV up to walking age. This will provide a benchmark for standard of care in the UK and will help to reduce geographical variability in treatment and outcomes. Appropriate dissemination and implementation will be key to its success. Cite this article: Bone Joint J 2022;104-B(6):758–764

Abstract. Introduction. With respect to survivorship following total knee arthroplasty (TKA), joint registries consistently demonstrate higher revision rates for both sexes in those less than 55 years. The current study analyses the survivorship of 500 cementless TKAs performed in this age group in a high-volume primary joint unit where cementless TKA has traditionally been used for the majority of patients. Methods. This was a retrospective review of 500 consecutive TKAs performed in patients under the age of 55 between March 1994 and April 2017. The primary outcome measure for the study was all-cause revision. Secondary outcome measures included clinical, functional and radiological outcomes. Results. The all-cause revision rate was 1.6% (n=8) at a median of 55.7 months. Four were revised for infection, 2 for stiffness, 1 for aseptic loosening of the tibial component and 1 patella was resurfaced for anterior knee pain. The aseptic revision rate was 0.8% (n=4). Twenty-seven (5.4%) patients underwent a manipulation under anaesthetic (MUA). Including those who underwent MUA, 6.8% (n=34) underwent other non-revision procedures. Conclusion. Survivorship in our unit in this young patient cohort was excellent with an aseptic revision rate of 0.8% at 59.7 months using a fully cementless construct. The MUA rate was higher than expected

Background. Total Ankle Replacement (TAR) is an established treatment option for end-stage ankle arthritis. We analysed at minimum, 10-year patient-reported and clinical outcomes of 156 TARs from a single centre. We specifically compared outcomes between patients under 60 and over 60 at time of surgery. Methods. Data was collected retrospectively from our departmental patient database. It included all patients who underwent a TAR by a single surgeon between 2006 and 2010 and patients were divided into those under 60 and those over 60 at the time of surgery. Patient reported outcomes (PROMs), including WOMAC, SF-36 and patient satisfaction scores and complications were analysed preoperatively and at one, two, five and over 10 years postoperatively. Results. There were 156 patients included in this analysis, 61 were under 60 (mean age 50.29) and 95 were over 60 (mean age 69.12). A total of 12 patients had revision surgery, (nine in the under 60 group) and 52 patients were deceased at the time of analysis (10 in the under 60 group). At one year the over 60 group had less pain and better functional scores (p=0.02, p=0.017). At two, five and ten years there was no statistical difference in pain and function between groups. At two years the over 60s reported less stiffness and quicker return to activities of daily living (p=0.007, p=0.001). However, at five and 10 years there was no statistical difference in any domain. Conclusions. This study demonstrates that age does not correlate with a significant difference in pain or functional outcomes in patients who have TAR, at over 10 years follow up. The higher revision rates in the younger group may correlate with higher functional demand and lower mortality rate

Total hip arthroplasty (THA) has high rates of patient satisfaction; however patient expectations for recreational and sporting activities are not always met. Our study aimed to identify preoperative factors that predict whether patient expectations for sporting or recreational activity are met 12 months following THA. Patient reported outcome measures (PROMs) were collected prospectively from 2015-2018 at one private hospital in Sydney. Age, gender, postcode, weight, and height were recorded preoperatively. Included participants underwent primary THA by one of the investigating surgeons. Univariable and multivariable analyses were performed with an expectation fulfilment score used as the primary outcome variable. Preoperative predictor variables included: age, gender, BMI, Socio-economic Indexes for Areas (SEIFA), Oxford Hip Score, Hip Osteoarthritis Outcome Score, EQ-5D-5L and EQ Visual Analogue Scale (EQ VAS). 1019 participants were eligible and included. 13% reported that preoperative expectations of sport or recreation were not met at 12 months. Younger age, lower preoperative EQ VAS, and higher BMI were associated with failed expectations on multivariable analysis. Odds of failed expectations increased by 2% for every one year younger in age (OR= 0.98, 95% CI = 0.96 to 1.00, p=.048), by 2% for every one point lower on EQ VAS (OR=0.98, 95% CI = 0.98 to 0.99, p=.002), and by 4% for every one-point increase in BMI (OR = 1.04, 95% CI = 1.00 to 1.09, p=.042). Failure to have expectations met for sporting or recreational activity was associated with younger age, poorer general health, and high BMI. With a rise in younger patients who likely have higher physical demands, a tailored preoperative education is preferable to generic models to better manage patient expectations. Younger age, higher BMI, and poorer health may predict unmet expectations for sport and recreation after THA. Tailored education in these groups should be considered

Aims. Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures. Methods. This will be a multicentre, parallel-group, individually randomized controlled superiority trial. We aim to recruit 344 participants aged 50 years and older with an ankle fracture treated surgically or non-surgically from at least 20 NHS hospitals. Participants will be randomized 1:1 using a web-based service to supervised rehabilitation (four to six one-to-one physiotherapy sessions of tailored advice and prescribed home exercise over three months), or self-directed rehabilitation (provision of advice and exercise materials that participants will use to manage their recovery independently). The primary outcome is participant-reported ankle-related symptoms and function six months after randomization, measured by the Olerud and Molander Ankle Score. Secondary outcomes at two, four, and six months measure health-related quality of life, pain, physical function, self-efficacy, exercise adherence, complications, and resource use. Due to the nature of the interventions, participants and intervention providers will be unblinded to treatment allocation. Conclusion. This study will assess whether supervised rehabilitation is more effective than self-directed rehabilitation for adults aged 50 years and older after ankle fracture. The results will provide evidence to guide clinical practice. At the time of submission, the trial is currently completing recruitment, and follow-up will be completed in 2024. Cite this article: Bone Jt Open 2024;5(6):499–513

Aims. The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution. Methods. All 1,049 primary THAs which were undertaken in 860 patients aged under 50 years between 1988 and 2018 in our tertiary care institution were included. We used cemented implants in both primary and revision surgery. Impaction bone grafting was used in patients with acetabular or femoral bone defects. Kaplan-Meier analyses were used to determine the survival of primary and revision THA with the endpoint of revision for any reason, and of revision for aseptic loosening. Results. The mean age of the patients at the time of the initial THA was 38.6 years (SD 9.3). The mean follow-up of the THA was 8.7 years (2.0 to 31.5). The rate of survival for all primary THAs, acetabular components only, and femoral components only at 20 years’ follow-up with the endpoint of revision for any reason, was 66.7% (95% confidence interval (CI) 60.5 to 72.2), 69.1% (95% CI 63.0 to 74.4), and 83.2% (95% CI 78.1 to 87.3), respectively. A total of 138 revisions were performed. The mean age at the time of revision was 48.2 years (23 to 72). Survival of all subsequent revision procedures, revised acetabular, and revised femoral components at 15 years’ follow-up with the endpoint of revision for any reason was 70.3% (95% CI 56.1 to 80.7), 69.7% (95% CI 54.3 to 80.7), and 76.2% (95% CI 57.8 to 87.4), respectively. A Girdlestone excision arthroplasty was required in six of 860 patients (0.7%). Conclusion. The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. We showed that our philosophy of using impaction bone grafting in patients with acetabular and femoral defects is a very suitable option when treating young patients. Surgeons should realize that knowledge of the outcome of subsequent revision surgery, which is inevitable in young patients, must be communicated to this group of patients prior to their initial THA. Cite this article: Bone Joint J 2022;104-B(3):368–375

Introduction and Objective. In multiple trauma patients, as well as in the healing of isolated fractures (Fx) with heavy bleeding (trauma haemorrhage, TH), complications occur very often. This is particularly evident in elderly patients over 65 years of age. Since these accompanying circumstances strongly influence the clinical course of treatment, the influence of age on bone regeneration after femoral fracture and severe blood loss was investigated in this study. Materials and Methods. 12 young (17–26 weeks) and 12 old (64–72 weeks) male C57BL / 6J mice per group were examined. The fracture group Fx underwent an osteotomy after applying an external fixator. The THFx group also received blood pressure-controlled trauma hemorrhage (35 mmHg for 90 minutes) and reperfusion with Ringer's solution for 30 minutes. The Sham group received only the catheter and one external fixator. μCT scans of the femora were performed in vivo after 2 weeks and ex vivo after 3 weeks. Histological and biomechanical examinations were also carried out. The statistical significance was set at p ≤ 0.05. The non-normally distributed data were analyzed using the Mann-Whitney-U or Kruskal-Wallis test. Results. The histology showed less mineralized bone in the fracture gap in old animals of the Fx (25.41% [1.68%]) and THFx groups (25.50% [4.07%]) compared with the young ones (34.20% [6.36%], p = 0.003; 34.31% [5.12%], p=0.009). Moreover, a severe blood loss lead to more cartilage in both young (6.91% [5.08%]) and old animals (4.17% [1.42%]) compared to animals with only a fracture (2, 45% [1.04%], p=0.004; 2.95% [1.12%], p=0.032). In old animals (11.37 / nm. 2. [17.17 / nm. 2. ]) in contrast the young mice with an isolated fracture (33.6/nm. 2. [8.83/nm. 2. ]) fewer osteoclasts were present (p=0.009). Therefore, the severe blood loss further reduced the number of osteoclasts only in young animals (16.83/nm. 2. [6.07/nm. 2. ]) (p=0.004). In the in vivo μCT, after 2 weeks, a lower volume of bone, cortex and callus was found in old THFx animals (3.14 mm. 3. [0.64 mm. 3. ]); 1.01 mm. 3. [0.04 mm. 3. ]; 2.07 mm. 3. [0.57 mm. 3. ]) compared with the Fx animals (4.29 mm. 3. [0.74 mm. 3. ], p=0.008; 1.18 mm. 3. [0, 25 mm. 3. ], p=0.004; 3.02 mm. 3. [0.77 mm. 3. ], p=0.008) After 3 weeks, the ex vivo μCT scans also showed a reduced callus percentage in old THFx animals (61.18% [13.9 9%]), as well as a low number of trabeculae (1.81 mm. -1. [0.23 mm. -1. ]) compared to animals without blood loss (68.72% [15.71%], p = 0.030; 2.06mm. -1. [0.37mm. -1. ], p=0.041). In the biomechanical test, a reduced elasticity limit of the old THFx mice (7.75 N [3.33 N]) in contrast to the old Fx (10.24 N [3.32 N]) animals was shown (p=0.022). Conclusions. A severe blood loss has a higher negative effect on the healing, morphometry, and biomechanical properties of previously fractured femora in old compared to young individuals

Aims. Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?. Methods. A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on PROMs, ROM, and complications. PROMs and ROM results were reported descriptively and a meta-analysis of complications was conducted. Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42021228329). Results. A total of 29 studies met the inclusion and exclusion criteria. The mean Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score was 19.6 (SD 7.5) for HA and 38 (SD 11.9) for TEA and the mean abbreviated version of DASH was 17.2 (SD 13.2) for HA and 24.9 (SD 4.8) for TEA. The Mayo Elbow Performance Score was the most commonly reported PROM across included studies, with a mean of 87 (SD 5.3) in HA and 88.3 (SD 5) in TEA. High complication rates were seen in both HA (22% (95% confidence interval (CI) 5 to 44)) and TEA (21% (95% CI 13 to 30), but no statistically significant difference identified. Conclusion. This systematic review has indicated PROMs and ROM mostly favouring HA, but with a similarly high complication rate in the two procedures. However, due to the small sample size and heterogeneity between studies, strength of evidence for these findings is low. We propose further research in the form of a national randomized controlled trial. Cite this article: Bone Joint J 2022;104-B(5):559–566

Abstract. Osteoarthritis is a common articular cartilage disorder and causes a significant global disease burden. Articular cartilage has a limited capacity of repair and there is increasing interest in the use of cell-based therapies to facilitate repair including the use of Mesenchymal Stromal Cells (MSCs). There is some evidence in the literature that suggests that advancing age is associated with declining MSC function, including reduced proliferation and differentiation potential, and greater cellular apoptosis. In our study, we first performed a systematic review of the literature to determine the effects of chronological age on the in vitro properties of MSCs, and then performed a laboratory study to investigate these properties. We initially conducted a PRISMA systematic review of the literature to review the evidence base for the effects of chronological age on the in vitro properties of MSCs including cell numbers, expansion, cell surface characterization and differentiation potential. This was followed by laboratory based experiments to assess these properties. Tissue from patients undergoing total knee replacement surgery was used to isolate MSCs from the infrapatellar fat pad using a method developed in our laboratory. The growth kinetics was determined by calculating the population doublings per day. Following expansion in culture, MSCs at P2 were characterised for a panel of cell surface markers using flow cytometry. The cells were positive for CD73, CD90 and CD105, and negative for CD34 and CD45. The differentiation potential of the MSCs was assessed through tri-lineage differentiation assays. Chronological age-related changes in MSC function have important implications on the use of these cells in clinical applications for an ageing population. The results from this study will be used to plan further work looking at the effects of chronological age on cellular senescence and identify pathways that could be targeted to potentially reverse any age-related changes

Aims. To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA). Methods. A consecutive series of 811 ankles (789 patients) that underwent TAA between May 2003 and December 2013 were enrolled. The influence of age on clinical outcome, including the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and pain according to the visual analogue scale (VAS) was assessed. In addition, the risk for revision surgery that includes soft tissue procedures, periarticular arthrodeses/osteotomies, ankle joint debridement, and/or inlay exchange (defined as minor revision), as well as the risk for revision surgery necessitating the exchange of any of the metallic components or removal of implant followed by ankle/hindfoot fusion (defined as major revision) was calculated. Results. A significant improvement in the AOFAS hindfoot score and pain relief between the preoperative assessment and the last follow-up was evident. Age had a positive effect on pain relief. The risk for a minor or major revision was 28.7 % at the mean follow-up of 5.4 years and 11.0 % at a mean follow-up of 6.9 years respectively. The hazard of revision was not affected by age. Conclusion. The clinical outcome, as well as the probability for revision surgery following TAA, is comparable between younger and older patients. The overall revision rate of the Hintegra total ankle is comparable with other three component designs. TAA should no longer be reserved for low demand elderly patients, but should also be recognized as a viable option for active patients of younger age. Cite this article: Bone Joint J 2020;102-B(7):925–932

Aims. Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group. Methods. Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years. Results. All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia. Conclusion. Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061

Aims. This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults. Methods. This is a retrospective cohort study of 182 displaced TPFs in 180 patients aged ≥ 60 years, over a 12-year period with a minimum follow-up of one year. The mean age was 70.7 years (SD 7.7; 60 to 89), and 139/180 patients (77.2%) were female. Radiological assessment consisted of fracture classification; pre-existing knee osteoarthritis (OA); reduction quality; loss of reduction; and post-traumatic OA. Fracture depression was measured on CT, and the volume of defect estimated as half an oblate spheroid. Operative management, complications, reoperations, and mortality were recorded. Results. Nearly half of the fractures were Schatzker II AO B3.1 fractures (n = 85; 47%). Radiological knee OA was present at fracture in 59/182 TPFs (32.6%). Primary management was fixation in 174 (95.6%) and acute TKA in eight (4.4%). A total of 13 patients underwent late TKA (7.5%), most often within two years. By five years, 21/182 12% (95% confidence interval (CI) 6.0 to 16.7) had required TKA. Larger volume defects of greater depth on CT (median 15.9 mm vs 9.4 mm; p < 0.001) were significantly associated with TKA requirement. CT-measured joint depression of > 12.8 mm was associated with TKA requirement (area under the curve (AUC) 0.766; p = 0.001). Severe joint depression of > 15.5 mm (hazard ratio (HR) 6.15 (95% CI 2.60 to 14.55); p < 0.001) and pre-existing knee OA (HR 2.70 (95% CI 1.14 to 6.37); p = 0.024) were independently associated with TKA requirement. Where patients with severe joint depression of > 15.5 mm were managed with fixation, 11/25 ultimately required TKA. Conclusion. Overall, 12% of patients aged ≥ 60 years underwent TKA within five years of TPF. Severe joint depression and pre-existing knee arthritis were independent risk factors for both post-traumatic OA and TKA. These features should be investigated as potential indications for acute TKA in older adults with TPFs. Cite this article: Bone Joint J 2024;106-B(1):28–37

Aims. Highly cross-linked polyethylene (HXLPE) has greatly improved the durability of total hip arthroplasty (THA) in young patients because of its improved wear characteristics. Few studies have followed this population into the second decade, and therefore the purpose of this investigation was to evaluate the clinical outcome for THA patients 50 years of age and younger at a minimum of 15 years postoperatively. The second purpose was to evaluate the radiological findings secondary to wear or mechanical failure of the implant. Methods. Between October 1999 and December 2005, 105 THAs were performed in 95 patients (53 female, 42 male) aged 50 years and younger (mean 42 years (20 to 50)). There were 87 patients (96 hips) that were followed for a minimum of 15 years (mean 17.3 years (15 to 21)) for analysis. Posterior approach was used with cementless fixation with a median head size of 28 mm. HXLPE was the acetabular bearing for all hips. Radiographs were evaluated for polyethylene wear, radiolucent lines, and osteolysis. Results. Clinical outcomes showed significant improvement of mean Harris Hip Scores from 52.8 (SD 13.5) preoperatively to 94.8 (SD 7.6) postoperatively. One hip was revised for recurrent instability, and there were no infections. No hips were revised for mechanical loosening or osteolysis. Mean polyethylene linear wear was 0.04 mm/year and volumetric wear was 6.22 mm. 3. /year, with no significant differences between head size or material. Osteolysis was not present in any of the hips. Conclusion. The use of HXLPE in THA for patients aged 50 years and younger has performed exceptionally well without evidence of significant wear causing mechanical loosening or necessitating revision. The radiolucent lines of the acetabular component must be followed to determine the prognostic significance. This investigation represents the longest clinical follow-up of a large, consecutive cohort of patients aged 50 years or younger with THA using HXLPE. This long-term analysis found negligible polyethylene wear, no incidence of aseptic loosening, and excellent clinical outcomes at and beyond 15 years of follow-up. Cite this article: Bone Joint J 2021;103-B(7 Supple B):78–83

Aims. To evaluate mid-to long-term patient-reported outcome measures (PROMs) of endoprosthetic reconstruction after resection of malignant tumours arising around the knee, and to investigate the risk factors for unfavourable PROMs. Methods. The medical records of 75 patients who underwent surgery between 2000 and 2020 were retrospectively reviewed, and 44 patients who were alive and available for follow-up (at a mean of 9.7 years postoperatively) were included in the study. Leg length discrepancy was measured on whole-leg radiographs, and functional assessment was performed with PROMs (Toronto Extremity Salvage Score (TESS) and Comprehensive Outcome Measure for Musculoskeletal Oncology Lower Extremity (COMMON-LE)) with two different aspects. The thresholds for unfavourable PROMs were determined using anchor questions regarding satisfaction, and the risk factors for unfavourable PROMs were investigated. Results. The thresholds for favourable TESS and COMMON were 64.8 and 70.4 points, respectively. Multivariate analysis showed that age at surgery (p = 0.004) and postoperative leg length discrepancy (p = 0.043) were significant risk factors for unfavourable TESS results, while age at surgery (p < 0.001) was a significant risk factor for unfavourable COMMON-LE results. Following receiver operating characteristic analysis, the threshold for both TESS and COMMON-LE was 29 years of age at surgery. Additionally, a leg length discrepancy of 8.2 mm was the threshold for unfavourable TESS. Conclusion. Patients aged > 29 years at the time of surgery require appropriate preoperative counselling and adequate postoperative physical and socioemotional support. Reconstruction equivalent to the length of the resected bone can reduce the risk of functional disabilities in daily living. Cite this article: Bone Jt Open 2023;4(12):906–913

The 22 year survivorship of metal on metal hip resurfacing arthroplasty (RSA) is reported to be 94.3% with expert surgeons, in males with head sizes greater than 48mm. The 2023 National Joint Registry (NJR) report estimates survivorship of all RSA at 19 years to be 85%. This estimate includes all designs, head sizes and females. Our aim was to estimate the survivorship of RSA currently available for implantation (males only, head size >48mm, MatOrtho Adept or Smith and Nephew Birmingham Hip Resurfacing (BHR)) in those under 55 years, performed by all surgeons, compared to conventional THR. We performed a retrospective analysis of the NJR. We included all males under 55 years who had undergone BHR or Adept RSA with head size greater than 48mm. Propensity score matching was used to produce two comparable groups of patients for RSA or conventional THR. We matched in a 3:1 ratio (THR:RSA) using sex, ASA, BMI group, age at primary procedure, surgeon volume, diagnosis and surgeon grade as covariates. The primary analysis was survivorship at 18 years. Time-to-revision was assessed using Kaplan-Meier curves. Cox's proportional hazard models were used to investigate between group differences. 4839 RSA were available for analysis. After matching the RSA and THR groups were well balanced in terms of covariates. Survivorship at 18 years was 93.7% (95% CI 89.9,96.2) in the RSA group and 93.9% (90.5,96.0) in the THR group. Despite these similar estimates the adjusted hazard ratio was 1.40 (95% CI 1.18, 1.67 p<0.001) in favour of THR. Survivorship of the currently available RSA in males under 55 was 93.7% at 18 years, however THR survivorship was superior to RSA. These results, generalisable to UK practice, should be set against perceived benefits in functional status offered in RSA when counselling patients

Aims. To provide normative data that can assess spinal-related disability and the prevalence of back or leg pain among adults with no spinal conditions in the UK using validated questionnaires. Methods. A total of 1,000 participants with equal sex distribution were included and categorized in five age groups: 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 to 69 years. Individuals with spinal pathologies were excluded. Participants completed the Scoliosis Research Society-22 (SRS-22r), visual analogue scale (VAS) for back/leg pain, and the EuroQol five-dimension index (EQ-5D/VAS) questionnaires, and disclosed their age, sex, and occupation. They were also categorized in five professional groups: doctors, nurses, allied health professionals, office workers, and manual workers. Results. The mean age of all participants was 43.8 years (20 to 69). There was no difference in the SRS-22r, EQ-5D, or VAS scores among male and female participants (p > 0.05). There was incremental decrease in SRS-22r total scores as the age increased. The mean EQ-5D index score (0.84) ranged little across the age groups (0.72 to 0.91) but reduced gradually with increasing age. There was difference between the SRS-22r total score (4.51), the individual domain scores, and the EQ-5D score (index: 0.94 and VAS: 89) for the doctors’ group compared to all other occupational categories (p < 0.001). Doctors had a younger mean age of participants, which may explain their improved spinal health. There was no difference in the total or sub-domain SRS-22r and EQ-5D scores between the other four occupational groups. Conclusion. This study provides the first normative data for the SRS-22r, EQ-5D, and VAS for back/leg pain questionnaires among adults in the UK. We recorded an excellent correlation between the three assessment tools with individuals who reported less back and leg pain having better quality of life and greater function. The participants’ age, rather than their sex or profession, appears to be the major determinant for spinal health and quality of life. Cite this article: Bone Jt Open 2022;3(2):130–134

Seniors make up 16.9 percent of the Canadian population. Furthermore, the number of Canadians who are 65 years or older is increasing at an average rate of 20 percent every 5 years. In 2017, Sing etal reported that there is an increasing number of patients undergoing degenerative scoliosis surgery with the largest increase attributed to patients aged 65–69 years followed by those aged 70–74 years. Therefore, the purpose of this study is to assess the effectiveness of undergoing spinal surgery to correct degenerative spinal scoliosis in the ever-growing number of elderly patients. We hypothesize that age is not an independent prognostic factor of patients' outcomes followings degenerative scoliosis surgery. A retrospective review of prospectively collected data within the Canadian Spine Outcome and Research Network (CSORN) was conducted. Data was analyzed using IBM-SPSS. ANOVA was used to analyze continuous variables while Chi Square test was used to analyze categorical variables. Significance level was p < 0.05. There were 165 patients identified from the registry who met the inclusion criteria, 94 patients (57 %) were female. There were 102 (61.8 %) patients who were 65 years or older. The overall average age was 66.6 years (range 35–84, SD 8.6). There were 27 intra-operative complications, 44 peri-operative complications and 18 post operative complications. There was no statistically significant difference between the two age groups with regards to risk of developing intra-operative, perioperative and post operative complications. Patients who underwent degenerative scoliosis surgery reported an average improvement of 2.95±3.32, 3.64±3.50, 16.84±20.44 points on the back-pain scale, leg pain scale and the Oswestry Disability Index (ODI) respectively, there was no statistically significant differences in these measures between the two age groups. As the number of patients undergoing degenerative scoliosis surgery increases, clinicians will need to determine which factors will significantly impact patients' outcomes following surgery. This study shows that age is not an independent prognostic factor when it comes to patients' outcomes following degenerative scoliosis surgery. In the future, research should examine the impact of age in conjunction with factors such as frailty, comorbidities and functional status on patient outcomes

Aims. MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. Methods. A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing. Results. Two-year postoperative mean outcome scores were: Tegner 6.5 (2 to 10); Lysholm 89.8 (SD 10.4; 52 to 100); and IKDC subjective 86.8 (SD 11.8; 51 to 100). The objective IKDC score was 86% A (128 patients), 13% B (19 patients), and 1% C (two patients). Mean side-to-side anterior laxity difference (134 N force) was 0.6 mm (SD 1.8; -4.1 to 5.6). Mean graft SNQ was 2.0 (SD 3.5; -14 to 17). Graft Howell scores were I (61%, 91 patients), II (25%, 37 patients), III (13%, 19 patients), and IV (1%, two patients). There was no correlation between either Howell score or SNQ with instrumented anterior or Lysholm, Tegner, and IKDC scores, nor was any correlation found between patient age and ACL graft SNQ or Howell score. Conclusion. The two-year postoperative MRI appearances of four-strand, semitendinosus ACL autografts (as measured by SNQ and Howell score) do not appear to have a relationship with postoperative functional scores, instrumented anterior laxity, or patient age at surgery. Other tools for analysis of graft maturity should be developed. Cite this article: Bone Jt Open 2021;2(8):569–575

Introduction and Objective. Chronic tendinopathy is a multifactorial disease and a common problem in both, athletes and the general population. Mechanical overload and in addition old age, adiposity, and metabolic disorders are among the risk factors for chronic tendinopathy but their role in the pathogenesis is not yet unequivocally clarified. Materials and Methods. Achilles tendons of young (10 weeks) and old (100 weeks) female rats bred for high (HCR) and low (LCR) intrinsic aerobic exercise capacity were investigated. Both Achilles tendons of 28 rats were included and groups were young HCR, young LCR, old HCR, and old LCR (n = 7 tendons per group/method). In this rat model, genetically determined aerobic exercise capacity is associated with a certain phenotype as LCR show higher body weight and metabolic dysfunctions in comparison to HCR. Quantitative real-time PCR (qPCR) was used to evaluate alterations in gene expression. For histological analysis, semi-automated image analysis and histological scoring were performed. Results. Age-related downregulation of tenocyte marker genes (Tenomodulin), genes related to matrix modelling and remodeling (Collagen type 1, Collagen type 3, Elastin, Biglycan, Fibronectin, Tenascin C), and Transforming growth factor beta 3 (Tgfb3) were detected in tendons from HCR and LCR. Furthermore, inflammatory marker Cyclooxygenase 2 (Cox2) was downregulated, while Microsomal prostaglandin E synthase 2 (Ptges2) was upregulated in tendons from old HCR and old LCR. No significant alteration was seen in Interleukin 6 (Il6), Interleukin 1 beta (Il1b), and Tumor necrosis factor alpha (Tnfa). Histological analysis revealed that Achilles tendons of old rats had fewer and more elongated tenocyte nuclei compared to young rats, indicating a reduced metabolic activity. Even though higher content of glycosaminoglycans as a sign of degeneration was found in tendons of old HCR and LCR, no further signs of tendinopathy were detectable in histological evaluation. Conclusions. Overall, aging seems to play a prominent role in molecular and structural alterations of Achilles tendon tissue, while low intrinsic exercise capacity did not cause any changes. Even though tendinopathy was not present in any of the groups, some of the shown age-related changes correspond to single characteristics of chronic tendon disease. This study gives an insight into tendon aging and its contribution to molecular and cellular changes in Achilles tendon tissue

Mitochondrial dysfunction has been demonstrated in aging and osteoarthritic tissues. We investigated knee joints of prematurely aging mitochondrial DNA mutator mice (PolgD275A) to evaluate a relationship between mitochondrial dysfunction and osteoarthritis. Cartilage damage was evaluated using OARSI histopathology grading and osteoclast numbers were quantified by tartrate-resistant acid phosphatase staining in wild type, heterozygous and homozygous PolgD275A mice. Subchondral cortical plate and epiphyseal trabecular bone structures were determined by micro-computed tomography. Apoptosis in cartilage and subchondral bone tissues was studied using an indirect TUNEL method. Homozygous mutants displayed osteopenia of the epiphyseal trabecular bone and subchondral cortical plate in comparison to wild type and heterozygous mutants. Subchondral osteopenia was associated with a strong increase of osteoclast numbers (0.88±0.30/mm bone perimeter) compared to heterozygous (0.25±0.03/mm) and wild type mice (0.12±0.04/mm). Wild type mice as well as hetero- and homozygous mutants displayed low-grade cartilage degeneration due to loss of cartilage proteoglycans. In contrast, chondrocyte hypertrophy was more abundant in the homozygous mice. There were no differences in chondrocyte apoptosis rates between groups. Prematurely ageing mtDNA mutator mice with or without further mechanic or metabolic stimuli might serve as a valuable model for further experimental studies on aging-induced osteoporotic OA phenotype