Aim. Acute post-surgical infection is one of the most serious complications after instrumented thoracolumbar fusion with an incidence of 0.7%-12%. Acute infection can lead to an increase in morbidity, mortality, and economic costs for the healthcare system. The main objective of our study was to determine the variables associated with a higher risk of acute infection after thoracolumbar instrumentation in our center. Methods. We conducted an observational case-control study including instrumented fusions of the thoracolumbar spine performed between 2015 and 2021 at our institution. We included patients with thoracolumbar fusions after a fracture or for the treatment of degenerative pathology. We analyzed demographic variables related to the surgical procedure, the causative microorganism of infection, the outcome of infection treatment, and complications. We performed a descriptive analysis of all variables and a univariate comparison of cases and controls. The dichotomous variables were compared using the Fisher test, while the quantitative variables were compared using the Student's T-test. A p-value of <0.05 is taken into account to consider the statistical significance. SPSS v25 Windows program was used for statistical analyses. Results. 455 patients were included, 53% were male with a mean age of 60 years. 35% of patients had a BMI (Body Mass Index) >30, 21.1% were classified as ASA (American Society of Anesthesiologists) >3, 15.8% were diabetic, and 2.6% were under chronic corticosteroid treatment. In 34.1% of the fusions, the procedure lasted more than 3 hours. We identified 26 post-surgical acute infections (5.7%). Patients with an infection had a higher prevalence of diabetes (14.7% vs 34.6% p=0.012), chronic corticosteroid treatment (2.1% vs 11.5% p=0.026), and a higher percentage of surgeries with duration > 3 hours (32.4% vs. 61.1%, p=0.019). A trend towards significance was also observed in patients classified as ASA >3 (20.3% vs. 34.6%, p=0.088), and BMI >30 (33.8% vs. 53.8%, p=0.054). No significant differences were observed in the rest of the variables studied. The most frequent causative microorganism was S.epidermidis (38%), followed by S.aureus (34%) and polymicrobial infections (34%). Conclusions. There is a significant increase in infection in diabetic patients, patients with chronic corticosteroid treatment, and in surgeries lasting > 3 hours

Hip resurfacing may be a useful surgical procedure when patient selection is correct and only implants with superior performance are used. In order to establish a body of evidence in relation to hip resurfacing, pseudotumour formation and its genetic predisposition, we performed a case-control study investigating the role of HLA genotype in the development of pseudotumour around MoM hip resurfacings. All metal-on-metal (MoM) hip resurfacings performed in the history of the institution were assessed. A total of 392 hip resurfacings were performed by 12 surgeons between February 1st 2005 and October 31st 2007. In all cases, pseudotumour was confirmed in the preoperative setting on Metal Artefact Reduction Sequencing (MARS) MRI. Controls were matched by implant (ASR or BHR) and absence of pseudotumour was confirmed on MRI. Blood samples from all cases and controls underwent genetic analysis using Next Generation Sequencing (NGS) assessing for the following alleles of 11 HLA loci (A, B, C, DRB1, DRB3/4/5, DQA1, DQB1, DPB1, DPA1). Statistical significance was determined using a Fisher's exact test or Chi-Squared test given the small sample size to quantify the clinical association between HLA genotype and the need for revision surgery due to pseudotumour. Both groups were matched for implant type (55% ASR, 45% BHR in both the case and control groups). According to the ALVAL histological classification described by Kurmis et al., the majority of cases (63%, n=10) were found to have group 2 histological findings. Four cases (25%) had group 3 histological findings and 2 (12%) patients had group 4 findings. Of the 11 HLA loci analysed, 2 were significantly associated with a higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) and 4 were noted to be protective against pseudotumour formation (DQA1*03:01:01, DRB1*04:04:01, C*01:02:01, B*27:05:02). These findings further develop the knowledge base around specific HLA genotypes and their role in the development of pseudotumour formation in MoM hip resurfacing. Specifically, the two alleles at higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) in MoM hip resurfacing should be noted, particularly as patient-specific genotype-dependent surgical treatments continue to develop in the future

Introduction: Deep infection continues to be the first most important early complication in knee arthroplasty. It is usual to apply standard prophylaxis to all patients, but it is not usual to use special measures in those of them who present a higher risk. Moreover, sometimes these patients are even not identified. Purpose: To analyse statistically significant risk factors for deep infection in patients with a knee arthroplasty. Patients and Methods:. Design: Case-control study. Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections. Case series: 32 consecutive patients with a deeply infected knee arthroplasty operated in the same Department of a University General Hospital. Control series: 100 randomly selected patients, operated in the same hospital and period of time, with no deep infection in their knee arthroplasty along follow-up. Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones. Results: The following risk factors were significantly more frequent (p< 0.05) in the patients with an infected knee arthroplasty:. Preoperative conditions: previous surgery in the same knee (25% vs 9%), chronic therapy with glucocorticoids (19% vs 4%), immunosuppressive treatments (16% vs 3%), and non-rheumatoid inflammatory arthritis (13% vs 0%). Patients in this case-control did not present a significant difference in the prevalence of rheumatoid arthritis, diabetes, obesity (BMI> 30), chronic liver diseases, or alcohol addiction. Intraoperative facts: a prolonged surgical time (149 min vs 108 min) and intraoperative fractures. Differences were not found in the amount of bleeding or need for transfusion. Postoperative events: secretion of the wound longer than 10 days (48% vs 0%), wound haematoma (36% vs 6%), new surgery in the knee (30% vs 0%), and deep venous thrombosis in lower limbs (10% vs 1%). Distant infections (risk for haematogenous seeding): deep cutaneous (27% vs 3%), generalized sepsis (7% vs 0%), upper and lower urinary tract (27% vs 5%), pneumonias and bronchopneumonias (27% vs 5%), and diverse abdominal focus (17% vs 1%). On the contrary, significant differences were not found in the prevalence of severe oral or dental infections. Epidemiologic characteristics: significant differences were not found in gender or in the prevalence of any aetiology. Conclusion: To identify significative risk factors for deep infection in knee arthroplasty is important:. to control and minimize these risk factors when present. when this is not possible not possible, to implement additional prophylactic measures

Introduction: Deep infection continues to be the second most important early complication in hip arthroplasty. It is usual to apply standard prophylaxis to all patients, but it is not usual to use special measures in those of them who present a higher risk. Moreover, sometimes these patients are even not identified. Purpose: To analyse statistically significant risk factors for deep infection in patients with a hip arthroplasty. Patients and Methods:. Design: Case-control study. Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections. Case series: 47 consecutive patients with a deeply infected hip arthroplasty operated in the same Department of a University General Hospital. Control series: 200 randomly selected patients, operated in the same hospital and period of time, with no deep infection in their hip arthroplasty along follow-up. Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones. Results: The following risk factors were significantly more frequent (p< 0.05) in the patients with an infected hip arthroplasty:. Epidemiologic characteristics: female gender, post-traumatic osteoarthritis (17% vs 3%). On the contrary, primary osteoarthritis is a “protective” factor. Preoperative conditions: previous surgery in the same hip (60% vs 6%), obesity (BMI> 30) (9% vs 1%), chronic therapy with glucocorticoids (13% vs 0%), immunosuppressive treatments, chronic liver diseases (20% vs 2%), alcohol addiction (13% vs 0%) and intravenous drug abuse. Patients in this case-control did not present a significant difference in the prevalence of diabetes (a recognised risk factor for spine and knee surgery) or rheumatoid arthritis. Intraoperative facts: a prolonged surgical time is the only significant risk factor (133 min vs 98 min), but differences were not found in the amount of bleeding, need for transfusion or intraoperative fractures. Postoperative events: secretion of the wound longer than 10 days (46% vs 8%), palpable deep haematoma (27% vs 1%), dislocation of the prosthesis (40% vs 6%), and need for new surgery in the hip (21% vs 1%). Distant infections (risk for haematogenous seeding): deep cutaneous (30% vs 8%), upper and lower urinary tract (36% vs 2%), pneumonias and bronchopneumonias (23% vs 5%), and diverse abdominal focus (14% vs 3%). On the contrary, significant differences were not found in the prevalence of severe oral or dental infections. Conclusion: To identify significative risk factors for deep infection in hip arthroplasty is important:. to control and minimize these risk factors when present. when this is not possible not possible, to implement additional prophylactic measures

A total of 31 patients, (20 women, 11 men; mean age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone resection-arthroplasty (RA) to a total hip replacement (THR) were compared with 93 patients, (60 women, 33 men; mean age 63.4 years old; 20 to 89), who had revision THR surgery for aseptic loosening in a retrospective matched case-control study. Age, gender and the extent of the pre-operative bone defect were similar in all patients. Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the control group (p = 0.01 and 0.003, respectively) and pre-operative leg length discrepancy (LLD) was greater in the RA group (p < 0.001). The post-operative clinical outcome was similar in both groups except for mean post-operative LLD, which was greater in the study group (p = 0.003). There was a significant interaction effect for LLD in the study group (p < 0.001). A two-way analysis of variance showed that clinical outcome depended on patient age (patients older than 70 years old had worse pre-operative pain, p = 0.017) or bone defect (patients with a large acetabular bone defect had higher LLD, p = 0.006, worse post-operative function p = 0.009 and range of movement, p = 0.005), irrespective of the group. . Despite major acetabular and femoral bone defects requiring complex surgical reconstruction techniques, THR after RA shows a clinical outcome similar to those obtained in aseptic revision surgery for hips with similar sized bone defects. Cite this article: Bone Joint J 2014;96-B:1478–84

Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF. This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed. The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups. Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate

Peri-prosthetic patellar fracture following resurfacing as part of total knee replacement (TKR) is an infrequent yet challenging complication. This case-control study was performed to identify clinical, radiological and surgical factors that increase the risk of developing a spontaneous patellar fracture after TKR. Patellar fractures were identified in 74 patients (88 knees) from a series of 7866 consecutive TKRs conducted between 1998 and 2009. After excluding those with a previous history of extensor mechanism realignment or a clear traumatic event, a metal-backed patella, any uncemented component or subsequent infection, the remaining 64 fractures were compared with a matched group of TKRs with an excellent outcome defined by the Knee Society score. The mean age of patients with a fracture was 70 years (51 to 81) at the time of TKR. Patellar fractures were detected at a mean of 13.4 months (2 to 84) after surgery. The incidence of patellar fracture was found to be strongly associated with the number of previous knee operations, greater pre-operative mechanical malalignment, smaller post-operative patellar tendon length, thinner post-resection patellar thickness, and a lower post-operative Insall-Salvati ratio. An understanding of the risk factors associated with spontaneous patellar fracture following TKR provides a valuable insight into prevention of this challenging complication

Aim

Mega-endoprosthesis over the last two decades have played a significant role in management of non-neoplastic cases for limb salvage for a variety of indications involving bone loss, infection, fracture and failed revision surgery. This is a retrospective case control study comparing outcomes of Mega-Endoprosthesis (MEP) in non-neoplastic cases with periprosthetic joint infections (PJI), with previous history of PJI and aseptic revision. Failure was defined as persistence/recurrence of infection, all cause revision, and antibiotic suppression during the follow up period. Secondary aims were identification of causative organisms, resistance profile and causative factors for revision surgery.

The hip-shelf procedure is less often indicated since the introduction of peri-acetabular osteotomy (PAO). Although this procedure does not modify pelvic shape, its influence on subsequent total hip arthroplasty (THA) is not known. We performed a case-control study comparing THA after hip-shelf surgery and THA in dysplastic hips to determine: 1) its influence on THA survival, 2) technical issues and complications related to the former procedure. We performed a retrospective case-control study comparing 61 THA cases done after hip-shelf versus 63 THA in case-matched dysplastic hips (control group). The control group was matched according to sex, age, BMI, ASA and Charnley score, and bearing type. We compared survival and function (Harris, Oxford-12), complications at surgery, rate of bone graft at cup insertion, and post-operative complications. The 13-year survival rates for any reason did not differ: 89% ± 3.2% in THA after hip shelf versus 83% ± 4.5% in the controls (p = 0.56). Functional scores were better in the control group (Harris 90 ± 10, Oxford 41/48) than in the hip-shelf group (Harris 84.7 ± 14.7, Oxford 39/48) (p = 0.01 and p = 0.04). Operative time, bleeding and rate of acetabular bone grafting (1.6 hip-shelf versus 9.5 control) were not different (p > 0.05). Postoperative complication rates did not differ: one transient fibular nerve palsy and two dislocations (3.2%) in the hip-shelf group versus four dislocations in the control group (6.3%). The hip-shelf procedure does not compromise the results of a subsequent THA in dysplastic hips. This procedure is simple and may keep its indications versus PAO in severely subluxed hips or in case of severe femoral head deformity

Total hip arthroplasty (THA) outcome in patients with osteonecrosis of the femoral head ONFH) are excellent, however, there is controversy when compared with those in patients with osteoarthritis (OA). Reduced mineralization capacity of osteoblasts of the proximal femur in patients with ONFH could affect implant fixation.

We asked if THA fixation in patients with ONFH is worse than in those with OA.

We carried out a prospective comparative case (OA)-control (ONFH) study of patients undergoing THA at our hospital between 2017 and 2019. The minimum follow-up was 2 years. Inclusion criteria were patients with uncemented THA, younger than 70 years old, a Dorr femoral type C and idiopathic ONFH. We compared the clinical (Merlé D'Aubigné-Postel score) and radiological results related with implant positioning and fixation. Engh criteria and subsidence were assessed at the immediate postoperative, 12 weeks, 6 months, 12 months and yearly. Osteoblastic activity was determined by mineralization assay on primary cultures of osteoblasts isolated from trabecular bone samples collected from the intertrochanteric area obtained during surgery.

Group 1 (ONFH) included 18 patients and group 2 (OA), 22. Average age was 55.9 years old in group 1 and 61.3 in group 2. (p=0.08). There were no differences related with sex, Dorr femoral type or femoral filling. The mean clinical outcome score was 17.1 in group 1 and 16.5 in group 2 (p=0.03). There were no cases of dislocation, infection, or revision surgery in this series. There were 5 cases (28%) of femoral stem subsidence greater than 3mm within 6 first months in group 1 and 1 case (4.5%) in group 2 (p=0.05).

Although there were no significant differences related to clinical results, bone fixation was slower, and a greater subsidence was observed in patients with ONFH. Greater femoral stem subsidence was associated with a lower capacity for mineral nodule formation in cultured osteoblasts. The surgical technique could influence THA outcome in patients with reduced mineralization capacity of osteoblasts.

Osteoarthritis (OA) is a disease of the synovial joint with synovial inflammation, capsular contracture, articular cartilage degradation, subchondral sclerosis and osteophyte formation contributing to pain and disability. Transcriptomic datasets have identified genetic loci in hip and knee OA demonstrating joint specificity. A limited number of studies have directly investigated transcriptional changes in shoulder OA. Further, gene expression patterns of periarticular tissues in OA have not been thoroughly investigated. This prospective case control series details transcriptomic expression of shoulder OA by analysing periarticular tissues in patients undergoing shoulder replacement for OA as correlated with a validated patient reported outcome measure of shoulder function, an increasing (clinically worsening) QuickDASH score. We then compared transcriptomic expression profiles in capsular tissue biopsies from the OA group (N=6) as compared to patients undergoing shoulder stabilisation for recurrent instability (the control group, N=26). Results indicated that top ranked genes associated with increasing QuickDASH score across all tissues involved inflammation and response to stress, namely interleukins, chemokines, complement components, nuclear response factors and immediate early response genes. Some of these genes were upregulated, and some downregulated, suggestive of a state of flux between inflammatory and anti-inflammatory signalling pathways. We have also described gene expression pathways in shoulder OA not previously identified in hip and knee OA, as well as novel genes involved in shoulder OA.

Summary Statement. In a retrospective study, FE-based bone strength from CT data showed a greater ability than aBMD to discriminate proximal femur fractures versus controls. Introduction. Personalised Finite Element (FE) models from Computed Tomography (CT) data are superior to bone mineral density (BMD) in predicting proximal femoral strength in vitro [Cody, 1999]. However, results similar to BMD were obtained in vivo, in retrospective classification of generic prevalent fractures [Amin, 2011] and in prospective classification of femoral fractures [Orwoll, 2009]. The aim of this work is to test, in a case-control retrospective study, the ability of a different, validated FE modelling procedure [Schileo, 2008] to: (i) discriminate between groups of proximal femoral fractures and controls; (ii) individually classify fractures and controls. Patients & Methods. 55 women (22 incident low-trauma proximal femur fractures and 33 controls) were enrolled in 3 clinical centres in Emilia Romagna region, Italy. All received a full femoral CT and DXA exams (in acute conditions for fractured cases) with a standardised protocol. Femoral neck aBMD was measured from DXA. FE models were built from CT (right femur for controls, intact for fractured) [Schileo, 2008]. Differently from existing works, FE strength was calculated for a range of 12 physiological directions of hip joint reactions [Bergmann, 2001] and 10 fall directions [Grassi, 2012]. Bone strength (in stance and fall) was the minimum load inducing on the femoral neck surface an elastic principal strain value greater than the yield limit [Bayraktar, 2004]. Fracture classification was analysed through logistic regressions and AUC of ROC curves. Results. Mean FE strength and aBMD were significantly lower in the fractured than in the control group (33%, p<0.0001 for strength; 12% p=0.01 for aBMD). Logistic regression on single variables. All classifiers were significant (p<0.001, AUC=0.88 for both stance and fall FE strength, p=0.02, AUC=0.72 for aBMD). The statistical power of the logistic regressions [Vaeth, 2004] was >0.9 for FE strength, 0.86 for aBMD. Logistic regressions on multiple variables. Only FE strength was retained significant (p<0.001, AUC=0.88) when including aBMD in the regression. Adding age to the logistic regression, FE strength and age (but not aBMD) remained significant, with AUC=0.95. Discussion. FE strength could discriminate the fractured group better than aBMD and than [Keyak, 2011]. FE strength was a better fracture classifier than aBMD, and obtained AUC values slightly higher than [Amin, 2011; Orwoll, 2009]. The high statistical power mildens the small sample numerosity. Cases and controls were not age matched, but FE strength and age were found to be independent classifiers. In conclusion the proposed FE method was superior to aBMD in the classification of proximal femoral fractures

Purpose of the study: Tibial osteotomy to correct for varus deformity is a well defined procedure. Survival has reached 80% at ten years. Nevertheless, a number of early failures are related to inadequate initial correction. Computer assisted surgery has demonstrated its efficacy for knee arthroplasty. We hypothesised that it could also improve the reliability of correction for tibial osteotomy. Material and method: From 2007, in a prospective case-control study, 34 tibial wedge osteotomies were performed, 17 were computer assisted (Navitrack, Orthosoft) with plate fixation (Tomofix, Synthès) without wedge insertion; the objective was valgus measuring 2 to 5°. Results: The two series were comparable for age (54.2±6 and 55.7±4.5), body mass index (28.9±6.2 and 28.7±5.7), and varus deformity (7.2±3 and 6.2±6) respectively in the standard and navigated groups. Osteoarthritis was more severe in the navigated group, with five patients stage 2 and 12 stage 2 versus one stage 1, 12 stage 2 and 4 stage 3 in the standard group (p=0.0152). The duration of the operation was not longer in the navigation group (p)0.2779). Comparisons were made for alignment at three months, between the groups and in relation to the preoperative data. There was no significant difference between the intraoperative navigation alignment and the alignment measured at 3 months: 3.6±6 and 2.5±3 at 3 months (p=0.2187). At 3 months, there was no significant difference in alignment between the two groups with 3.22 and 2.5±1.6 valgus in the standard and navigation groups respectively (p=0.2136). The objective was achieved in 25 patients: 12 in the standard group and 13 in the navigated group. In the navigation group, there were four failures, no cases of over correction, two cases of insufficient valgus at 1.5, one neutral alignment, and one recurrent varus. In the standard group, there were five failures with two over corrections at 7 and 8, two under corrections at 0 and 1, and 1 recurrent varus at 4. Discussion: We were unable to prove that navigation improves the reliability of the correction but it did appear to avoid important errors, particularly over correction. Few series have compared standard varus navigated osteotomies, and all published series have been small. Our study has the advantage of being monocentric with two comparable series of patients. The sample size nevertheless remains small and the follow-up short

Background: Congenital talipes equinovarus (CTEV) is a common developmental disorder of the foot, affecting between 1 and 4.5 babies per 1000 live births. The etiology is not well elucidated. While both genetic and environmental factors are implicated, no specific genes have been identified and little is known about environmental risk factors. Methods: We conducted a case-control study of idiopathic congenital talipes equinovarus (ICTEV) in the United Kingdom. 194 cases and 60 controls were recruited. Pedigrees were obtained for 162 cases. Results: The rank of the index pregnancy, maternal education and cesarean delivery were significantly associated with ICTEV risk in a multivariate model. There were suggestions that maternal use of folic acid supplements in the three months before the pregnancy decreased ICTEV risk, and that parental smoking during the pregnancy increased risk. One quarter of pedigrees showed a family history of CTEV, and autosomal dominant inheritance was suggested in some of these. Conclusion: Uterine restriction did not appear to have a strong influence on ICTEV development in our study. Large population-based studies are needed to clarify the etiology of this common developmental disorder

Aims: As inflammation plays a key role in the etiology of intervertebral disc degeneration, we suggest a possible contribution of pro-inflammatory gene polymorphisms in the pathogenesis of adolescent idiopathic scoliosis (AIS). The nucleus pulposus of scoliotic discs responds to exogenous stimuli by secreting interleukin-6 (IL-6) and other inflammatory cytokines. The association between matrix metalloproteinases (MMPs) and disc degeneration has been reported by several investigators. A human MMP-3 promoter 5A/6A gene polymorphism regulates MMP-3 genes expression, while the G/C polymorphism of the promoter region of IL-6 gene influences levels and functional activity of the IL-6 protein. Methods: We conducted a case-control study to investigate whether the 5A/6A polymorphism of the MMP-3 gene and the G/C polymorphism of the promoter region of IL-6 gene were associated with susceptibility to AIS. Results: The frequency of the 5A/5A genotype of MMP-3 gene polymorphism in patients with scoliosis was almost 3 times higher than in controls (30.2 % vs 11.2 %, p 0.001) and the frequency of the G/G genotype of IL-6 gene polymorphism in patients with scoliosis was almost 2 times higher than in controls (52.8 % vs 26.2 %, p < 0.001). 5A/5A genotype of MMP-3 gene polymorphism and G/G genotype of IL-6 gene polymorphism are independently associated with an higher risk of scoliosis (odds ratio respectively 3.34 and 10.54). Conclusions: This is the first study that has evaluated the possibility that gene variants of IL-6 and MMPs might be associated with scoliosis and suggests that MMP-3 and IL-6 promoter polymorphisms constitute important factors for the genetic predisposition to scoliosis

Background: Relatively little is known about the risk factors for carpal tunnel syndrome (CTS) in the community. Previous studies have generally assessed smaller numbers of patients in specialist clinics, or in particular occupations. Therefore, we have performed a case-control study using the West Midlands General Practice Research Database. Methods: Our cases were all patients with a recorded diagnosis of CTS; four controls per case were individually matched by age, sex and general practice. Information on constitutional, hormonal and musculoskeletal factors was extracted and analysed by conditional logistic regression. Results: Our dataset included 3,391 cases; 2,444 (72%) were female, mean age at diagnosis was 45.8 years: and 13,564 matched controls. Multivariate analysis showed that the risk factors associated with CTS were previous wrist fracture (OR = 2.29, 95% CI: 1.67–3.12), rheumatoid arthritis (OR = 2.23, 95% CI: 1.57–3.17), osteoarthritis (OR = 1.89, 95% CI: 1.65–2.17), BMI (BMI 30–40, OR = 2.06, 95% CI: 1.79–2.38), diabetes (OR = 1.51, 95% CI: 1.24–1.84), the use of insulin (OR = 1.52, 95% CI: 1.06–2.18), sulphonylureas (OR = 1.45, 95% CI: 1.07–1.97), metformin (OR = 1.20, 95% CI: 0.84–1.72) and thyroxine (OR = 1.36, 95% CI: 1.08–1.70). Smoking habit, hormone replacement therapy, the combined oral contraceptive pill and oral corticosteroids were not associated with CTS. Conclusions: Rheumatoid arthritis, wrist fracture, osteoarthritis, and an increased Body Mass Index were the most important risk factors for CTS that we identiþed. The combined oral contraceptive, hormone replacement therapy, prednisolone and smoking are not associated with CTS

Open reduction and internal fixation (ORIF) with trans-articular screws or dorsal plating is the standard surgical technique for displaced Lisfranc injuries. This aim of this study is to compare the clinical outcomes of percutaneous reduction and internal fixation (PRIF) of low energy Lisfranc injuries with a matched, control group of patients treated with ORIF.

Over a seven-year period (2012–2019), 16 consecutive patients with a low energy Myerson B2-type injury were treated with PRIF. Patient demographics were recorded within a prospectively maintained database at the institution. This study sample was matched for age, sex and mechanism of injury to a control group of 16 patients with similar Myerson B2-type injuries treated with ORIF. Clinical outcome was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ).

At a mean follow up of 43.0 months (95% CI 35.6 – 50.4), both the AOFAS and MOXFQ scores were significantly higher in the PRIF group compared to the control ORIF group (AOFAS 89.1vs 76.4, p=0.03; MOXFQ 10.0 vs 27.6, p=0.03). There were no immediate postoperative complications in either group. At final follow up, there was no radiological evidence of midfoot osteoarthritis in any patient in the PRIF group. Three patients in the ORIF group developed midfoot osteoarthritis, one of whom required midfoot fusion.

PRIF is a technically simple, less invasive method of operative stabilisation of low energy Lisfranc injures which also appears to be associated with better mid-term clinical outcomes compared to ORIF.

The study sought to determine the results of labral restoration among patients over age 60 compared to a cohort of younger adults.

21 consecutive patients over age 60 undergoing labral repair with minimum one-year follow-up were compared to a contemporaneous group of 21 patients age 18–55 matched for gender, degree of chondral damage, and associated FAI or dysplasia.

Follow-up averaged 18.9 months (12 to 24 months). The study group averaged 63.2 years (61 to 71); with 20 FAI and one dysplasia. 19 had acetabular articular damage (2 grade IV, 11 grade III, 5 grade II, 1 grade I) and 6 had femoral changes (1 grade IV, 5 grade 3). The control group averaged 35.8 years (20 to 54).

Average improvement among the study group was 28.1 points modified Harris Hip Score (mHHS) and 37.5 points iHOT; and among the control group, 21.2 points mHHS and 37.1 points iHOT. There was no statistically significant difference between the two groups in the amount of improvement, with statistically and clinically significant improvement noted in both. Two study group patients underwent total hip arthroplasty (THA) at average 10 months with one control group THA at 11 months. All three converted to THA had combined grade IV acetabular and grade III femoral damage. There were no repeat arthroscopies and no complications in either group.

We conclude that patients over age 60 can benefit from arthroscopic labral repair with improved outcomes, modest rates of conversion to THA, and small risk of complication. Results are comparable to younger adults. Combined bipolar grade IV or grade III articular damage is a harbinger of conversion to THA, regardless of age.

Introduction: The purposes of this study are to investigate the inter-relationship between Stulberg class and radiographic hip osteoarthritis (OA) in patients with Legg-Calvé-Perthes disease (LCP) and to determine whether LCP patients develop hip OA more often than sex- and age-matched individuals.

Material and Methods: 167 LCP patients presented to our institution from 1941 to 1962. All patients were treated conservatively by a Thomas splint. Retrospectively medical records and radiographs were retrieved.

At follow-up weight-bearing AP pelvis radiographs were obtained. OA was present when the minimum joint space width was < 2.0 mm. Radiographs of sex- and age-matched controls were obtained from The Copenhagen City Heart Study.

The following criteria for exclusion were applied:

insufficient or missing radiographs

52 patients (55 hips) were enrolled in the study and 115 patients (136 hips) were excluded. Mean age for men at follow-up was 53 years and for women 55 years.

Results: In the LCP group four hips of 50 hips had OA compared to one hip of 107 hips in the control group. One patient out of 41 in Stulberg class I/II had OA compared to three out of nine in Stulberg class III/IV/V.

Conclusion: LCP patients have a significant higher risk of having hip OA compared to a sex- and age-matched control group, p=0.04 [OR=8.5 (CI=0.8–428.8)]. Patients in Stulberg class III, IV or V have a significantly increases risk of hip OA compared to patients in Stulberg class I or II, p=0.03 [OR=13.7 (CI 1.9–97.1)].

Introduction: Poor long-time results in patients with Legg-Calvé-Perthes disease (LCP) are most often due to degenerative hip disease. The purpose of this study was to investigate if patients with LCP have an increased rate of total hip replacement (THR) compared to sex- and age-matched persons.

Material and Methods: 167 LCP patients presented to our institution from 1941 to 1962. All patients were treated conservatively by a Thomas splint. Retrospectively medical records and radiographs were retrieved. Data from the Danish Hip Replacement Register and the Registries of the National Board of Health were collected to get information regarding the number of the patients who had a THR.

Radiographs of sex- and age-matched controls for the follow-up group were obtained from The Copenhagen City Heart Study.

The following criteria for exclusion were applied

emigrated persons,

135 patients (156 hips) were enrolled in this study and 32 patients (35 hips) were excluded.

Results: 20 hips out of 156 hips in patients with LCP have had a THR. Mean age at operation for the women was 50 years and 44 years for the men. None of the sex- and age-matched persons have had a THR.

Conclusion: LCP patients had a significantly higher risk of THR surgery compared to sex- and age-matched control persons, (p< 0.00 [OR= 49.0 (CI 8.2-infinite)]).

Introduction

Femoroacetabular impingement (FAI) is a morphological hip joint deformity associated with pain and early degenerative changes. Cam-type FAI is prevalent in young male athletes. While biomechanical deficiencies (decreased hip muscle strength and range of motion (ROM)) have been associated with symptomatic cam-type FAI (sFAI), results have been conflicting and little is known about biomechanical characteristics during dynamic tasks.

Background

Polymethylmethacrylate (PMMA) has been used for total knee arthroplasty (TKA) as a method of fixation; however, its durability has been questionable for the long-term use because of the loosening after the cement deterioration, its vulnerability toward infectious resistance, and a smaller amount of healthy bone left for the knee revision surgery. Especially, a decrease of bone density on the proximal tibia has been believed to be triggered as a result of stress shielding. When compared with a cemented TKA, a cementless TKA reduces the amount of bone loss after surgery. In 1999, the Trabecular Metal (TM), with its main composition being the porous tantalum metal, became available as a choice of the porous cementless knee joint prosthesis. The characteristics of porous tantalum metal are its great affinity to the bone as well as its similarity to cancellous bone. The porous tantalum metal starts to bond with osteoblasts, and fills up 80% of porous structure in one year; therefore, it has been characterized by its higher initial fixation strength. However, it is questionable if strong fixation strength due to bone ingrowth between the tibial tray mainly made up with the porous tantalum metal and a cancellous bone will continually be kept. Bobyn, JD, Dunbar et al. have acknowledged the existence of bone ingrowth based on the radiographic evaluation; however, their data had not been quantified in their report. In this study, the bone ingrowth density have periodically quantified using 3D bone morphometric software (TRI/3D-BON64.RATOC) after taking CT of the knee joint prosthesis.

There has never been a study of whether intra-articular steroid injections of arthritic hips can alter the outcomes of subsequent arthritis management, particularly total hip arthroplasty (THA). In this study forty patients with a history of steroid injection of the hip and subsequent THA are examined retrospectively for infections, revisions, and prospectively-gathered hip scores, as compared to matched non-steroid controls. The steroid group had an increased incidence of pain, infectious workup under usual care, and two revisions for deep infection within three years. We suggest that steroid injections of hips should be avoided in patients who are candidates for THA.

Despite the lack of demonstrated efficacy of intra-articular steroid injections for hip arthritis, the procedure is often utilized for diagnostic differentiation from spine pain, and attempted therapeutic management of painful hip arthritis. However, in the era of total hip arthroplasty (THA) the safety of this practice must be evaluated in the context of whether the injections pose any potential for complicating subsequent surgery, particularly with regard to infection. In this study, forty patients who underwent THA and had a history of previous steroid injection were compared retrospectively to forty carefully-matched patients who underwent THA in the same time period but had no history of prior steroid injection. Outcome measures included whether there was a septic workup under usual care, and this occurred in 20% of steroid patients within the first thirty-six months post-THA, as opposed to 0% in the controls. Furthermore, in a detailed analysis of Harris and Oxford scores, there was in the steroid group a higher incidence of night pain, increased severity of pain, and reduced function with activities of daily living at one year. There were two revisions for deep infection in the steroid group, and one revision for dislocation in each of the steroid and control groups. Pending the completion of the study, we provisionally suggest that steroid injection of hips may be ill-advised in a patient who will be a candidate for THA in the future. This suggestion is based primarily on the incidence of pain and infectious complications in the first postoperative year.

Funding Dr Kaspar holds academic research grants from McMaster University and from The Physicians’ Services Incorporated (PSI) Foundation, the latter of which was used to finance this study and the continuation thereof. There are no commercial grants or conflicts of interest.

In this study, 40 patients who underwent total hip arthroplasty (THA) and had a history of previous steroid injections were compared retrospectively with 40 carefully matched patients who underwent THA in the same period but had never received steroid injections. The development of sepsis under standard care was one of the outcome measures. This occurred in 20% of steroid patients within the first 36 months after THA, compared to 0% in the control group. Further, in a detailed analysis of Harris and Oxford scores, patients treated with steroid had a higher incidence of night pain, more severe pain, and greater loss of function in activities of daily living at one year. There were two revisions for deep infection in the steroid and control groups.

Based on the incidence of pain and infectious complications in the first postoperative year, and pending completion of the study, we provisionally suggest that steroid injection of hips may be ill advised in patients who are likely candidates for future THA.

BACKGROUND

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

Introduction

Adolescent idiopathic scoliosis (AIS) is associated with low bone mineral density, which could be related to its etiopathogenesis. Apart from bone density, bone micro-architectures are equally important for better understanding of disease initiation and progression in AIS. Quantitative assessment of bone quality is hampered by the invasive nature of investigations, until recently when the high-resolution pQCT (XtremeCT) became available for revolutionary in-vivo microimaging and derivation of bone micro-architectural parameters. Our objective was to use this powerful instrument to study bone qualities in AIS and compare findings with those from healthy controls.

Purpose: The purpose of this work was to assess the mechanical axis of 28 computer-assisted osteotomies (group A) with 28 manual osteotomies (group B) selected at random from 140 osteotomies performed between January 1997 and December 2000.

Material and methods: The populations were comparable for age, gender, side, degree of osteoarthritis (modified Ahlback stages) and varus malalignment (group A: 173±3.80° (160°–178°), group B 172.8±3.18° (164°–178°) using a pangonometer to measure the HKA angle). For 52 knees, open-wedge tibial osteotomy was performed and fixed with a tricalcium phosphate wedge (Biosorb(r)) and an AO T-plate. For four knees (two in group A and two in group B), a double tibial (open wedge) and femoral (closed wedge) osteotomy was used due to genu varum measuring greater than 15°. Preoperative planning for the classical method used a plumb line from the centre of the femoral head identified fluoroscopically. The Orthopilot(r) computer-assisted method also relied on preoperative planning but intraoperative control was based on computer acquisitions of the centre of the hip, the knee and the ankle. The objective of the intervention was to obtain a mechanical axis between 182° and 186°. All knees were evaluated with pangonometry at three months to check axis correction.

Results: In group A, the mean postoperative HKA was 183±0.99° (181°–185°). In group B it was 184±2.28° (181°–189°). The objective was attained in 96% of knees in group A and in 71% in group B, giving a statistical difference between the absolute data (p=0.0248) and between the standard deviations (p=0.0015).

Conclusion: Computer-assisted osteotomy to correct for genu varum using the Orthopilot(r) method is feasible and remarkably reproducible. In our hands Orthopilot(r) enabled attaining the surgical objective set preoperatively. The kinetics of the acquisition of the centre of the hip, the knee, and the ankle associated with palpation of remarkable extra-articular points is an excellent method avoiding the need for intra-articular palpation which might complicate the surgical procedure.

Background and purpose

Sleep disturbance is frequently reported by people with chronic low back pain (CLBP >12 weeks), but there is limited knowledge of their sleep quality compared to healthy people. While disturbed sleep influences patients' mood, quality of life and recovery, few studies have comprehensively investigated sleep in CLBP. This study investigated differences in sleep profiles of people with CLBP, compared to age- and gender matched controls over seven consecutive nights.

Purpose of the study: The purpose of the study was compare dislocation rates of total hip arthroplasties (THA) implanted with a dual-mobility cup versus those implanted with a conventional cup.

Material and method: The first series (DM) included 105 patients who underwent first-intention THA implanted by one operator (DS) from January 2005 to June 2007. Dual mobility cups with a 28 mm head were implanted. There were 60 women and 45 men, mean age 76.6±5.65 years (range 53–93). Degenerative disease predominated (n=95, 90.%). The cups were Novae press-fit (SERF) (n=94), Stafit (Zimmer° 5N+5°? Avantage (Biomet) (n=5), and Gyros (Depuy) (n=1). The second series (S) included 108 patients who underwent the same procedure performed by the same operator (DS) from January 2003 to June 200 for the same indication. This series was the control series. There were 56 women and 52 men, mean age 74.19±5.9 years (range 53–87). Degenerative disease predominated (n=100, 92.6%). All implantations used metal-polyethylene bearing with a 28 mm head. The implants were St Nabor cups (Zimmer) (n=44), Cédior cups (Zimmer (n=41), and sealed cups (n=22). The same femoral stem with a 12–14 cone was used in both series. The reduced posterior approach was used in all cases without section of the pyramidal tendon. Inclusion required at least one year follow-up. Fischer’s test was used to compare dislocation rates. Other variables were analysed with the chi-square test.

Results: Regarding the dual-mobility cup series (DM) there were no cases of dislocation. In the conventional cup series (S) there were five early dislocations (< 3 months), giving a rate of 4.63%. although the dislocation rate was obviously higher in the S series, the difference was at the limit of significance (p=0.0597). In addition, the DM population was slightly older than the S series (p=0.0026).

Background: Presently the aetiology of this common condition remains unclear. Previous research suggests that diabetes or epilepsy might increase the prevalence of the condition, but the evidence is inconsistent.

Methods: Our cases were all patients diagnosed with Dupuytren’s Disease, with two controls per case individually matched by age, sex, and general practice. Information on all diagnoses of diabetes and diabetic medication, and epilepsy and anti-epileptics was extracted. All analysis was adjusted for consulting behaviour to reduce ascertainment bias.

Results: There were 821 cases (1,642 controls), 588 (72%) of which were males. Mean age at diagnosis was 62 years. Prevalence = 0.2%. Diabetes was significantly associated with Dupuytren’s (OR 1.82). Insulin use was strongly associated with Dupuytren’s (OR = 4.33), as was metformin (OR = 3.67); the association was also present for sulphonlyureas (OR = 1.89). There was no association with epilepsy and Dupuytren’s (OR = 1.05). None of the treatments for epilepsy were associated with Dupuytren’s disease.

Conclusion:Diabetes is a significant risk factor for Dupuytren’s Disease. There is an increased risk for treated diabetes rather than diet controlled diabetes. Epilepsy and anti-epileptic medication are not associated with Dupuytren’s Disease. Ascertainment bias may explain the association observed in previous studies.

Purpose: Shoulder instability is a common problem affecting patients in their most active years resulting in an impact on their quality of life. The WOSI is a validated, disease-specific (shoulder instability) evaluative quality of life measure. It has not been tested for its ability to discriminate between those who require surgical care and those who do not. The purpose of this study is to determine if the WOSI can discriminate between surgical and non-surgical patients and between patients with different types of shoulder instability.

Method: Sixty patients with a confirmed diagnosis of shoulder instability were included as cases. Twenty had documented multidirectional instability requiring surgery: Group 1 Surgical MDI – 20 patients had documented recurrent traumatic anterior dislocations requiring surgery: Group 2 Surgical Anterior – 20 patients were first time anterior dislocators who were followed for a minimum one year who had no further recurrences and did not require surgery: Group 3 Non-Surgical First Time Anterior – The cases were compared to 60 age and gender matched control patients with no history of shoulder problems: Group 4 Control – WOSI scores were analyzed using a one-way ANOVA.

Results: The WOSI scores were as follows: Group 1 Surgical MDI- mean 30.5 (95% CI 23.1–37.8); Group 2 Surgical Anterior- mean 39.8 (95% CI 33.1–46.5); Group 3 Non-Surgical First time Anterior- mean 76.2 (95% CI 66.4–86.0) and Group 4 Control- mean 96.6 (95% CI 95.8–97.4). Based on the 95% Confidence Intervals, there were statistically significant differences between the two surgical groups (Group 1 Surgical MDI and Group 2 Surgical Anterior) compared to the non-surgical patients (Group 3 Non Surgical First Time Anterior) and the controls (P=0.000). There is a trend to discriminate between the two surgical groups (P=0.079).

Conclusion: The WOSI Index clearly discriminates between surgical and non-surgical patients with shoulder instability, and the control population with normal shoulders. There is a trend to discriminate between MDI and recurrent anterior traumatic dislocators.

Background: Recent studies have shown that local infiltration analgesia (LIA) improves outcome after total hip replacement (THA). No detailed information does exist to its influence on length of stay (LOS) after surgery. In this study we have evaluated LOS, pain treatment, mobilization, postoperative nausea and vomiting (PONV) and satisfaction in a period before and after implementing LIA in our department.

Patients and Methods: Patients diagnosed with primary osteoarthrosis of the hip scheduled for unilateral uncemented or hybrid THA were included in the study. All cases were recognized from a local database with prospective collected data on all patients undergoing THA in our department. Total 100 consecutive patients who did not have LIA from September 1st 2006 were compared with 100 consecutive patients who received LIA from September 1st 2007. The two groups were unmatched and no patients were excluded. The solution used for LIA consisted of 200 mg Ropivacain, 30 mg Ketorolac and 1 mg Adrenaline dissolved in 100 ml isotone NaCl.

Results: Patients in the two groups were similar in regard to gender, age, body mass index (BMI) and ASA group, but did differ in duration of the surgical approach, the latter group having treatment with LIA in average had a 20 minuts shorter surgical approach. The patients who received LIA had reduced LOS, mean 3.8 days compared to 5.1 days in the gropu not treated with LIA (p< 0.001). Moreover, patients treated with LIA were significant more satisfied (p< 0.05) compared to the group who did not receive LIA. Moreover, patients treated with LIA were more frequently mobilized on day 1 after surgery (p< 0,001) and day 3 as well (p< 0.05). Also, patients treated with LIA had significantly reduced PONV on the day of operation (p< 0.05) and well as they consumed more nutrition (p< 0.001) the day after the operation. There was no difference in pain-score between the two groups except on day 3 (p< 0.05) in activity and at rest on the day of discharge (p< 0.05). No wound complications could be shown in any of the groups during the first 6 weeks after surgery.

Interpretation: Introducing LIA in our department changed the postoperative period detailed in several ways for patients undergoing THA. This study document that operative wound infiltration with multimodal drugs reduced LOS after THA, even though the reduced duration of operation may be some of the explanation. Moreover, LIA resulted in better mobilisation, less PONV and more satisfied patients. We recommend all unit undertaking THA to implement LIA in their daily praxis.

Aim: We have previously shown that long-term survival after hip fracture is highly dependent on age at the time of fracture and that fracture risk is similarly age-dependent. It has been suggested that the excess mortality occurs mainly during the first years after fracture, while mortality in a remaining life-time perspective is not well studied. The aim of this study was to evaluate short- and long-term mortality in relation to cause of death in a cohort of patients with hip fracture in comparison with the back-ground population.

Methods: All adult patients suffering a hip fracture due to low energy trauma 1984–1985 in Malmö, Sweden were identified; 1029 cases (766 women, 263 men). The cases were compared with two age- and gender matched controls from the same background population, all alive and living in the catchment area when the hip fracture occurred. Date of death and cause of death were available through the national database, EPIC. Cases and controls were followed until death or up to 22 years.

Results: The median survival was 4.4 yrs (+/− 0.2 [CI 95% 4.0–4.8]) in hip fracture patients and 7.7 yrs (+/− 0.2 [CI 95% 7.3–8.1]) in controls, equal to a median loss of 3.3 yrs. Mortality rate continued to be elevated for approximately 10 yrs, thereafter observed mortality approached expected mortality. Mean survival was 2.9 years shorter in fracture cases compared to controls (6.4 yrs (+/− 0.2 [CI 95% 6.0–6.8]) versus 9.4 yrs (+/− 0.2 [CI 95% 9.1–9.7])). Ischemic heart failure was the major underlying cause of death (25%) both among cases and controls.

Conclusion: In hip fracture patients, excess mortality is evident both in the short- and long-term with an increased risk beyond 10 yrs. Nevertheless, the major causes of death were similar to that of controls.

Painful OA is linked to CNS changes in pain processing. Temporal summation of pain (TSP) is a measure of one such CNS change, central sensitization. TSP is defined using a series (≥0.33Hz) of painful stimuli and is a predictor of postoperative pain, experienced by 20% of patients after total knee replacement (TKR) surgery. This study has developed a protocol to use functional MRI to assess CNS changes in OA pain processing.

This pilot includes 3 participants with chronic knee OA pain awaiting TKR (62 ± 4.4) and 5 healthy volunteers (50 ± 13.6). 3-Tesla BOLD fMRI brain scans were recorded during short series of one second painful stimuli, applied using an automated inflatable cuff to the calf muscle of the leg with the affected knee or left side in healthy volunteers. The pain intensity at onset and during the 10 painful stimuli were recorded using a numerical rating scale. The pattern of brain activation was averaged across noxious stimuli, and the differential activation compared the 1st vs. 10th (last) stimulus. Bone marrow lesions (BMLs), synovitis and effusion size were scored from 3-Tesla knee MRI's using MOAKS scoring.

TSP was raised in OA patients compared to control group (p=0.023). TSP brain activity in the chronic OA patients displayed higher signal within the subgenual anterior cingulate (sgACC) compared to healthy volunteers. Knee MRI identified OA patient's exhibited higher BML scores (p=0.038) and more knee effusion (p=0.018), but the lack of synovitis did not differ from control group (p=0.107).

Enhanced TSP in chronic knee OA pain may be linked with augmented responses in emotional circuitry. BMLs and effusion size appear to contribute more with pain than synovitis. These results may help understand sensitization to improve outcomes for patients with knee OA undergoing TKR surgery.

Aims. Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. Methods. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. ‘Controls’ were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size. Results. Using a previously-reported ALVAL classification, the majority of pseudotumour-positive caseswere found to have intermediate-grade group 2 (n = 10; 63%) or group 3 (n = 4; 25%) histological findings. Two further patients (13%) had high-grade group 4 lesions. HLA-DQB1*05:03:01 (p = 0.0676) and HLA-DRB1*14:54:01 (p = 0.0676) alleles were significantly associated with a higher risk of pseudotumour formation, while HLA-DQA1*03:01:01 (p = 0.0240), HLA-DRB1*04:04:01 (p = 0.0453), HLA-C*01:02:01 (p = 0.0453), and HLA-B*27:05:02 (p = 0.0855) were noted to confer risk reduction. Conclusion. These findings confirm the association between specific HLA genotypes and the risk of pseudotumour development around MoM hip resurfacings. Specifically, the two ‘at risk’ alleles (DQB1*05:03:01 and DRB1*14:54:01) may hold clinical value in preoperative screening and prospective surgical decision-making. Cite this article: Bone Jt Open 2023;4(3):182–187

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures. A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections. Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance. Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics. This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study

Distal radius fractures (DRFs) are common injuries that represent 17% of all adult upper extremity fractures. Some fractures deemed appropriate for nonsurgical management following closed reduction and casting exhibit delayed secondary displacement (greater than two weeks from injury) and require late surgical intervention. This can lead to delayed rehabilitation and functional outcomes. This study aimed to determine which demographic and radiographic features can be used to predict delayed fracture displacement. This is a multicentre retrospective case-control study using radiographs extracted from our Analytics Data Integration, Measurement and Reporting (DIMR) database, using diagnostic and therapeutic codes. Skeletally mature patients aged 18 years of age or older with an isolated DRF treated with surgical intervention between two and four weeks from initial injury, with two or more follow-up visits prior to surgical intervention, were included. Exclusion criteria were patients with multiple injuries, surgical treatment with fewer than two clinical assessments prior to surgical treatment, or surgical treatment within two weeks of injury. The proportion of patients with delayed fracture displacement requiring surgical treatment will be reported as a percentage of all identified DRFs within the study period. A multivariable conditional logistic regression analysis was used to assess case-control comparisons, in order to determine the parameters that are mostly likely to predict delayed fracture displacement leading to surgical management. Intra- and inter-rater reliability for each radiographic parameter will also be calculated. A total of 84 age- and sex-matched pairs were identified (n=168) over a 5-year period, with 87% being female and a mean age of 48.9 (SD=14.5) years. Variables assessed in the model included pre-reduction and post-reduction radial height, radial inclination, radial tilt, volar cortical displacement, injury classification, intra-articular step or gap, ulnar variance, radiocarpal alignment, and cast index, as well as the difference between pre- and post-reduction parameters. Decreased pre-reduction radial inclination (Odds Ratio [OR] = 0.54; Confidence Interval [CI] = 0.43 – 0.64) and increased pre-reduction volar cortical displacement (OR = 1.31; CI = 1.10 – 1.60) were significant predictors of delayed fracture displacement beyond a minimum of 2-week follow-up. Similarly, an increased difference between pre-reduction and immediate post reduction radial height (OR = 1.67; CI = 1.31 – 2.18) and ulnar variance (OR = 1.48; CI = 1.24 – 1.81) were also significant predictors of delayed fracture displacement. Cast immobilization is not without risks and delayed surgical treatment can result in a prolong recovery. Therefore, if reliable and reproducible radiographic parameters can be identified that predict delayed fracture displacement, this information will aid in earlier identification of patients with DRFs at risk of late displacement. This could lead to earlier, appropriate surgical management, rehabilitation, and return to work and function

Aims. Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research. Methods. A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review. Results. A total of 362 studies met the inclusion criteria. Most were of total elbow arthroplasty (246; 68%), followed by radial head arthroplasty (100; 28%), distal humeral hemiarthroplasty (11; 3%), and radiocapitellar arthroplasty (5; 1%). Most were retrospective (326; 90%) and observational (315; 87%). The median sample size for all types of implant across all studies was 36 (interquartile range (IQR) 21 to 75). The median length of follow-up for all studies was 56 months (IQR 36 to 81). A total of 583 unique outcome descriptors were used and were categorized into 18 domains. A total of 105 instruments were used to measure 39 outcomes. Conclusion. We found that most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. Many outcomes have been used with many different instruments for their measurement, indicating a need to define a core set of outcomes and instruments for future research in this area. Cite this article: Bone Joint J 2022;104-B(10):1148–1155

Aims. Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries. Methods. This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation. Results. Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes. Conclusion. The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963–971

Aims. The aim of this study was to investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies. We asked: is there a difference in APP-PT between young symptomatic patients being evaluated for joint preservation surgery and an asymptomatic control group? Does APP-PT vary among distinct acetabular and femoral pathomorphologies? And does APP-PT differ in symptomatic hips based on demographic factors?. Methods. This was an institutional review board-approved, single-centre, retrospective, case-control, comparative study, which included 388 symptomatic hips in 357 patients who presented to our tertiary centre for joint preservation between January 2011 and December 2015. Their mean age was 26 years (SD 2; 23 to 29) and 50% were female. They were allocated to 12 different morphological subgroups. The study group was compared with a control group of 20 asymptomatic hips in 20 patients. APP-PT was assessed in all patients based on supine anteroposterior pelvic radiographs using validated HipRecon software. Values in the two groups were compared using an independent-samples t-test. Multiple regression analysis was performed to examine the influences of diagnoses and demographic factors on APP-PT. The minimal clinically important difference (MCID) for APP-PT was defined as > 1 SD. Results. There were no significant differences in APP-PT between the control group and the overall group (1.1° (SD 3.0°; -4.9° to 5.9°) vs 1.8° (SD 3.4°; -6.9° to 13.2°); p = 0.323). Acetabular retroversion and overcoverage groups showed higher mean APP-PTs compared with the control group (p = 0.001 and p = 0.014) and were the only diagnoses with a significant influence on APP-PT in the stepwise multiple regression analysis. All differences were below the MCID. The age, sex, height, weight, and BMI showed no influence on APP-PT. Conclusion. APP-PT showed no radiologically significant variation across different pathomorphologies of the hip in patients being assessed for joint-preserving surgery. Cite this article: Bone Joint J 2024;106-B(5 Supple B):3–10

Aims. Mechanical impingement of the iliopsoas (IP) tendon accounts for 2% to 6% of persistent postoperative pain after total hip arthroplasty (THA). The most common initiator is anterior acetabular component protrusion, where the anterior margin is not covered by anterior acetabular wall. A CT scan can be used to identify and measure this overhang; however, no threshold exists for determining symptomatic anterior IP impingement due to overhang. A case-control study was conducted in which CT scan measurements were used to define a threshold that differentiates patients with IP impingement from asymptomatic patients after THA. Methods. We analyzed the CT scans of 622 patients (758 THAs) between May 2011 and May 2020. From this population, we identified 136 patients with symptoms suggestive of IP impingement. Among them, six were subsequently excluded: three because the diagnosis was refuted intraoperatively, and three because they had another obvious cause of impingement, leaving 130 hips (130 patients) in the study (impingement) group. They were matched to a control group of 138 asymptomatic hips (138 patients) after THA. The anterior acetabular component overhang was measured on an axial CT slice based on anatomical landmarks (orthogonal to the pelvic axis). Results. The impingement group had a median overhang of 8 mm (interquartile range (IQR) 5 to 11) versus 0 mm (IQR 0 to 4) for the control group (p < 0.001). Using receiver operating characteristic curves, an overhang threshold of 4 mm was best correlated with a diagnosis of impingement (sensitivity 79%, specificity 85%; positive predictive value 75%, negative predictive value 85%). Conclusion. Pain after THA related to IP impingement can be reasonably linked to acetabular overhang if it exceeds 4 mm on a CT scan. Below this threshold, it seems logical to look for another cause of IP irritation or another reason for the pain after THA before concluding that impingement is present. Cite this article: Bone Joint J 2024;106-B(3 Supple A):97–103

Aims. The purpose of this study is to determine an individual’s age-specific prevalence of total knee arthroplasty (TKA) after cruciate ligament surgery, and to identify clinical and genetic risk factors associated with undergoing TKA. Methods. This study was a retrospective case-control study using the UK Biobank to identify individuals reporting a history of cruciate ligament surgery. Data from verbal history and procedural codes recorded through the NHS were used to identify instances of TKA. Patient clinical and genetic data were used to identify risk factors for progression from cruciate ligament surgery to TKA. Individuals without a history of cruciate ligament reconstruction were used for comparison. Results. A total of 2,576 individuals with a history of cruciate ligament surgery were identified, with 290 (11.25%) undergoing TKA. In patients with prior cruciate ligament surgery, prevalence of TKA was 0.75% at age 45 years, 9.10% at age 65 years, and 20.43% at age 80 years. Patients with prior cruciate ligament surgery were 4.6 times more likely to have undergone TKA by age 55 years than individuals without prior cruciate ligament surgery. In the cruciate ligament surgery cohort, BMI > 30 kg/m. 2. (odds ratio (OR) 4.01 (95% confidence interval (CI) 2.74 to 5.87)), a job that always involved heavy manual or physical labour (OR 2.72 (95% CI 1.57 to 4.71)), or a job that always involved walking and standing (OR 2.58 (95% CI 1.58 to 4.20)) were associated with greater TKA odds. No single-nucleotide polymorphism (SNP) was associated with risk of TKA following cruciate ligament surgery. Conclusion. Patients with a history of prior cruciate ligament surgery have substantially higher risk of TKA and undergo arthroplasty at a relatively younger age than individuals without a history of prior cruciate ligament surgery. Physically demanding work and obesity were associated with higher odds of TKA after cruciate ligament surgery, but no SNP was associated with risk of TKA. Cite this article: Bone Joint J 2024;106-B(3):249–255

Aims. This study investigates whether primary knee arthroplasty (KA) restores health-related quality of life (HRQoL) to levels expected in the general population. Methods. This retrospective case-control study compared HRQoL data from two sources: patients undergoing primary KA in a university-teaching hospital (2013 to 2019), and the Health Survey for England (HSE; 2010 to 2012). Patient-level data from the HSE were used to represent the general population. Propensity score matching was used to balance covariates and facilitate group comparisons. A propensity score was estimated using logistic regression based upon the covariates sex, age, and BMI. Two matched cohorts with 3,029 patients each were obtained for the adjusted analyses (median age 70.3 (interquartile range (IQR) 64 to 77); number of female patients 3,233 (53.4%); median BMI 29.7 kg/m. 2. (IQR 26.5 to 33.7)). HRQoL was measured using the three-level version of the EuroQol five-dimension questionnaire (EQ-5D-3L), and summarized using the Index and EuroQol visual analogue scale (EQ-VAS) scores. Results. Patients awaiting KA had significantly lower EQ-5D-3L Index scores than the general population (median 0.620 (IQR 0.16 to 0.69) vs median 0.796 (IQR 0.69 to 1.00); p < 0.001). By one year postoperatively, the median EQ-5D-3L Index score improved significantly in the KA cohort (mean change 0.32 (SD 0.33); p < 0.001), and demonstrated no clinically relevant differences when compared to the general population (median 0.796 (IQR 0.69 to 1.00) vs median 0.796 (IQR 0.69 to 1.00)). Compared to the general population cohort, the postoperative EQ-VAS was significantly higher in the KA cohort (p < 0.001). Subgroup comparisons demonstrated that older age groups had statistically better EQ-VAS scores than matched peers in the general population. Conclusion. Patients awaiting KA for osteoarthritis had significantly poorer HRQoL than the general population. However, within one year of surgery, primary KA restored HRQoL to levels expected for the patient’s age-, BMI-, and sex-matched peers. Cite this article: Bone Joint J 2023;105-B(4):365–372

Aims. To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients. Methods. We undertook a retrospective, case-control study of 67 patients at mean 3.5 years (SD 1.3; 1.3 to 6.1) after TPF (47 patients underwent fixation, and 20 nonoperative management). Patients completed EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, Lower Limb Function Scale (LEFS), and Oxford Knee Scores (OKS) for current and recalled prefracture status. Propensity score matching for age, sex, and deprivation in a 1:5 ratio was performed using patient level data from the Health Survey for England to obtain a control group for HRQoL comparison. The primary outcome was the difference in actual (TPF cohort) and expected (matched control) EQ-5D-3L score after TPF. Results. TPF patients had a significantly worse EQ-5D-3L utility (mean difference (MD) 0.09, 95% confidence interval (CI) 0.00 to 0.16; p < 0.001) following their injury compared to matched controls, and had a significant deterioration (MD 0.140, 95% CI 0 to 0.309; p < 0.001) relative to their preoperative status. TPF patients had significantly greater pre-fracture EQ-5D-3L scores compared to controls (p = 0.003), specifically in mobility and pain/discomfort domains. A decline in EQ-5D-3L greater than the minimal important change of 0.105 was present in 36/67 TPF patients (53.7%). Following TPF, OKS (MD -7; interquartile range (IQR) -1 to -15) and LEFS (MD -10; IQR -2 to -26) declined significantly (p < 0.001) from pre-fracture levels. Of the 12 elements of fracture care assessed, the most important to patients were getting back to their own home, having a stable knee, and returning to normal function. Conclusion. TPFs in older adults were associated with a clinically significant deterioration in HRQoL compared to preinjury level and age, sex, and deprivation matched controls for both undisplaced fractures managed nonoperatively and displaced or unstable fractures managed with internal fixation. Cite this article: Bone Jt Open 2023;4(4):273–282

Aims. Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme. Methods. This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender. Results. All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience. Conclusion. This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training. Cite this article: Bone Joint J 2023;105-B(7):821–832

The management of prosthetic joint infection (PJI) has been widely performed for total hip arthroplasties (THA), but none has compared it with hip resurfacing arthroplasty (RSA). We also carried out a retrospective case-control study comparing the surgical treatment of PJI by surgical debridement and implant retention between RSA and THA in order to clarify whether there was a difference in terms of (1) successful healing of PJI (2) functional scores after recovery (3) risk factors for recurrence of PJI. Our hypothesis was that simple debridement with prosthesis retention regardless of the timeframe allowed to obtain a higher success rate for RSA compared to THA. From 2010 to 2018, a single-center case-control study based on 3056 RSA found 13 PJI were age-matched (based on the 139 THA PJI treated) with 15 THA PJI (mean age of 53 years old (47–58) for THA and 59 (45–66) for RSA (p=0.34)). We compared their survival (absence of infectious recurrence) and the means differences between the 2 groups (demographical, clinical and biological data). There was no difference between the 2 groups concerning: age (p=0.3), BMI (p=0.4), initial diagnosis (p=0.4), operating time for primary surgery (p=0.3), the presence of a postoperative hematoma (p=0.4), the type of bacteria (p=0.5), the total duration of antibiotic therapy (p=0.9) and the type of antibiotic therapy (p=0.6). Early postoperative infections (less than 6 weeks) occurred in 7/13 RSA cases (54%) compared to 11/15 THA cases (73%). At the mean follow-up of 5 years (2–7), the success rate without recurrence was significantly higher in the RSA group 100% versus 66.7% (10/15) for the THA group (p=0.044). At the last follow-up, the Oxford Hip Score was higher in the RSA versus THA group's (14 versus 22 p=0.004). Simple surgical debridement an RSA without changing implants after PJI can be done regardless of the time to onset of infection. This is secondary to the absence of metaphyseal bone invasion and the low content of joint fluid

Osteoarthritis (OA) is the most common disorder of the Sternoclavicular Joint (SCJ). In our case-control study, we evaluated the relationship between clavicular length and OA at the SCJ. CT scans of adults presenting to the Emergency Department of our hospital were examined to look for OA, defined as the presence of osteophytes, subchondral cysts, or cortical sclerosis at the SCJ. Medial-most and lateral-most points of the clavicle were marked on the slices passing through the SC and AC joints respectively. Using x, y, and z-axis coordinates from the DICOM metadata, clavicular length was calculated as the distance between these two points with 3D geometry. Preliminary data of 334 SCJs from 167 patients (64% males, 36% females) with a mean age of 48.5 ± 20.5 years were analysed. Multivariate regression models revealed that age and clavicular length were independent risk factors for OA while gender did not reach statistical significance. A 1mm increase in length was associated with 9% and 7% reduction in the odds of developing OA on the left and the right respectively. Comparing the mean clavicular length using t-test showed a significantly shorter clavicle in the group with OA (145.8 vs 152.7, p=0.0001, left and 144.2 vs 150.3, p=0.0007, right). Our data suggest that the risk of developing OA at the SCJ is higher for shorter clavicles. This could be of clinical relevance in cases of clavicular fracture where clavicular shortening might lead to a higher risk of developing OA. Biomechanical studies are needed to find out the mechanism of this effect

Abstract. Introduction. In patients with bilateral unicompartmental knee osteoarthritis, simultaneous bilateral surgery is cost effective, with both patient-specific and wider socioeconomic benefits. There are concerns however regarding higher complication rates with bilateral knee surgery. This study compares simultaneous bilateral unicompartmental knee arthroplasty (UKA), to single side UKA in terms of complications and outcomes. Methodology. This is a retrospective case-control study of single side medial UKA patients (controls) and simultaneous bilateral medial UKA patients (cases). All patients underwent surgery between 2018 and 2022 by a single surgeon. The two cohorts were compared for perioperative blood loss (PBL), length of stay (LOS), complications (infections, blood clots, wound problems), Oxford Knee Score improvement (OKS) and revision surgery, with a follow-up period of up to 5 years. Results. 64 patients were followed up comprising 55 controls and 9 cases. Average length of stay for controls was 1.55 days and 2.22 days for cases (p=0.03). Average haemoglobin drop was 7.5g/l in controls and 12.8g/l in cases (p=0.04). The OKS improvement was comparable in both groups (p=0.95) with no complications and no revision surgery in either group. Conclusion. The statistically significant differences in PBL and LOS were not clinically relevant. There were no blood transfusions and postoperative haemoglobin was within normal range in more than 60% of cases. Simultaneous bilateral unicompartmental knee arthroplasty is a financially favourable and safe option for patients with bilateral knee medial unicompartmental osteoarthritis

Patients with Paget's Disease of Bone (PDB) more frequently require total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, controversy remains regarding their outcome. This project aims to evaluate the current literature regarding outcomes following THA and TKA in PDB patients. MEDLINE, EMBASE and Cochrane databases were searched on February 15th, 2022. Inclusion criteria comprised studies evaluating outcomes following THA/TKA in PDB patients. Quality of included studies was assessed using the Newcastle-Ottawa Scale. 19 articles (published between 1976–2022) were included, comprising 58,695 patients (48,766 controls and 10,018 PDB patients), from 209 potentially relevant titles. No study was of high quality. PDB patient pooled mortality was 32.5% at mean 7.8(0.1-20) years following THA and 31.0% at mean 8.5(2-20) years following TKA. PDB patient revision rate was 4.4% at mean 7.2(0-20) years following THA and 2.2% at mean 7.4(2-20) years following TKA. Renal complications, respiratory complications, heterotopic ossification, and surgical site infection were the most common medical and surgical complications. The largest systematic review, to date, evaluating outcomes following THA and TKA in PDB patients. All functional outcome scores improved. PDB patient revision rate was comparable to UK National Joint Registry. However, there is a significant need for prospective matched case-control studies to robustly compare outcomes in PDB patients with unaffected counterparts

Aims. The use of high tibial osteotomy (HTO) to delay total knee arthroplasty (TKA) in young patients with osteoarthritis (OA) and constitutional deformity remains debated. The aim of this study was to compare the long-term outcomes of TKA after HTO compared to TKA without HTO, using the time from the index OA surgery as reference (HTO for the study group, TKA for the control group). Methods. This was a case-control study of consecutive patients receiving a posterior-stabilized TKA for OA between 1996 and 2010 with previous HTO. A total of 73 TKAs after HTO with minimum ten years’ follow-up were included. Cases were matched with a TKA without previous HTO for age at the time of the HTO. All revisions were recorded. Kaplan-Meier survivorship analysis was performed using revision of metal component as the endpoint. The Knee Society Score, range of motion, and patient satisfaction were assessed. Results. Mean follow-up was 13 years (SD 3) after TKA in both groups. The 20-year Kaplan-Meier survival estimate was 98.6% in TKA post-HTO group (HTO as timing reference) and 81.4% in control group (TKA as timing reference) (p = 0.030). There was no significant difference in clinical outcomes, radiological outcomes, and complications at the last follow-up. Conclusion. At the same delay from index surgery (HTO or TKA), a strategy of HTO followed by TKA had superior knee survivorship compared to early TKA at long term in young patients. Level of evidence: III. Cite this article: Bone Jt Open 2023;4(2):62–71