Aims. Elective orthopaedic surgery was cancelled early in the COVID-19 pandemic and is currently running at significantly reduced capacity in most institutions. This has resulted in a significant backlog to treatment, with some hospitals projecting that waiting times for arthroplasty is three times the pre-COVID-19 duration. There is concern that the patient group requiring arthroplasty are often older and have more medical comorbidities—the same group of patients advised they are at higher risk of mortality from catching COVID-19. The aim of this study is to investigate the morbidity and mortality in elective patients operated on during the COVID-19 pandemic and compare this to a pre-pandemic cohort. Primary outcome was 30-day mortality. Secondary outcomes were perioperative complications, including nosocomial COVID-19 infection. These operations were performed in a district general hospital, with COVID-19 acute admissions in the same building. Methods. Our institution reinstated elective operations using a “Blue stream” pathway, which involves isolation before and after surgery, COVID-19 testing pre-admission, and separation of ward and theatre pathways for “blue” patients. A register of all arthroplasties was taken, and their clinical course and investigations recorded. Results. During a seven-month period, 340 elective arthroplasties were performed. There was zero mortality. One patient had a positive swab for COVID-19 while an inpatient, but remained asymptomatic. There were two readmissions within a 12-week period for hip dislocation. Patients had a mean age of 68 years (28 to 90), mean BMI of 30 kg/m. 2. (19.0 to 45.6), and mean American Society of Anesthesiologists grade of 2 (1 to 3). Conclusion. Results show no increased morbidity or mortality in this cohort of patients compared to the same hospital’s morbidity and mortality pre-COVID-19. The screened pathway for elective patients is effective in ensuring that patients can be safely operated on electively in an acute hospital. This study should reassure clinicians and patients that arthroplasties can be carried out safely when the appropriate precautions are in place. Cite this article: Bone Jt Open 2021;2(11):940–944

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

Aims. Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients. Methods. All NOF fracture patients presenting between March 2020 and May 2020 were included. Patients were divided into two subgroup: those with or without clinical and/or laboratory diagnosis of COVID-19. Data were collected on patient demographics, pattern of injury, complications, length of stay, and mortality. Results. Overall, 132 patients were included. Of these, 34.8% (n = 46) were diagnosed with COVID-19. Bacterial pneumonia was observed at a significantly higher rate in those patients with COVID-19 (56.5% vs 15.1%; p =< 0.000). Non respiratory complications such as acute kidney injury (30.4% vs 9.3%; p =0.002) and urinary tract infection (10.9% vs 3.5%; p =0.126) were also more common in those patients with COVID-19. Length of stay was increased by a median of 21.5 days in patients diagnosed with COVID-19 (p < 0.000). 30-day mortality was significantly higher in patients with COVID-19 (37.0%) when compared to those without (10.5%; p <0.000). Conclusion. This study has shown that patients with a neck of femur fracture have a high rate of mortality and complications such as bacterial pneumonia and acute kidney injury when diagnosed with COVID-19 within the perioperative period. We have demonstrated the high risk of in hospital transmission of COVID-19 and the association between the infection and an increased length of stay for the patients affected. Cite this article: Bone Joint Open 2020;1-11:669–675

Abstract. Background. Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Methods. A retrospective analysis of aged 80–100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby &Burton between 2016–2020. Results. Total 167 eligible patients, 163 octogenarians & 4 nonagenarians. Mean age was 82.78 ± 3.07 years. Mean length of hospital stay 4.79 ± 10.92 days. 76% were pain free at 3months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No association found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17patients suffered complications; dural tear (0.017%), post-op paralysis (0.017%), SSI(0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality.2year revision decompression rate was 0.011%. Conclusion. Posterior lumbar decompression without instrumented stablisation in elderly is safe & associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72hours of surgery. Careful selection & optimising patients with high BMI would reduced perioperative morbidity and mortality

Aims. The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA. Methods. A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity. Results. Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19. Conclusion. COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236–242

Aims. Using the Australian and New Zealand Hip Fracture Registry (ANZHFR) data, this study aimed to identify patient, fracture, and management factors associated with survival, mobility and residential status at 120 days. This will allow future interventions to target modifiable risk factors to improve the overall care of patients with hip fractures. Methods. All NZ patients from 2018 – 2020 were included. Baseline demographics, management factors, and outcomes were recorded. Key outcomes were change in walking status, residential status and survival at 120 days. Univariate analysis was performed to compare differences in demographics, surgical and management factors for the key variables. Multivariate analysis was conducted to identify factors independently associated with outcomes. Results. Data from 9432 patients were analysed. The average age was 82.8 years (SD 9.8). 70.3% were females. 39.5% of patients were cognitively impaired on admission, 71.4% were from their own residence. At 120 days post injury, 10.9% (1029) had died 1029 (10.9%), 15.3% (1034) had a decrease in their residential status, 44.9% (2966) had a reduction in walking ability. On multivariate analysis; older age (RR1.1/yr, p<0.001), male sex (RR1.7, P<0.001), cognitive impairment (RR2.2, p<0.001) and ASA>3 (RR3.7, p=0.015) were risk factors for death. Similarly, increasing age (RR1.1 per year, p<0.001), cognitive impairment (RR1.2, p=0.04) and ASA>3 (RR2.9, p=0.047) were significant risk factors for worsening residential status. Decreasing mobility was associated with extracapsular fractures (RR1.4, p=0.01). After adjustment for demographics, ASA and fracture type, performing total hip arthroplasty was preventative for both worsening residential status (RR0.23, p<0.001) and decreasing walking ability (RR 0.21, p<0.001). There was no significant survival, functional or revision differences for other fixation types. Conclusion. There is a significant decline in walking ability post hip fracture which may be a key contributor to long-term morbidity. The benefits of THA in preserving mobility and independence should be further investigated. Additional discharge planning and multi-disciplinary team input are likely required for high-risk patients of older age, with cognitive impairment and extracapsular fractures

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR. . Cite this article: Bone Joint J 2014; 96-B:1464–71

Aims. During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. Methods. This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. Results. COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. Conclusion. Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136–1145

Abstract. Introduction. Minimising postoperative complications and mortality in COVID-19 patients who were undergoing trauma and orthopaedic surgeries is an international priority. Aim was to develop a predictive nomogram for 30-day morbidity/mortality of COVID-19 infection in patients who underwent orthopaedic and trauma surgery during the coronavirus pandemic in the UK in 2020 compared to a similar period in 2019. Secondary objective was to compare between patients with positive PCR test and those with negative test. Methods. Retrospective multi-center study including 50 hospitals. Patients with suspicion of SARS-CoV-2 infection who had underwent orthopaedic or trauma surgery for any indication during the 2020 pandemic were enrolled in the study (2525 patients). We analysed cases performed on orthopaedic and trauma operative lists in 2019 for comparison (4417). Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. Results. Of the 2525 patients admitted for suspicion of COVID-19, 658 patients had negative preoperative test, 151 with positive test and 1716 with unknown preoperative COVID-19 status. Preoperative COVID-19 status, sex, ASA grade, urgency and indication of surgery, use of torniquet, grade of operating surgeon and some comorbidities were independent risk factors associated with 30-day complications/mortality. The 2020 nomogram model exhibited moderate prediction ability. In contrast, the prediction ability of total points of 2019 nomogram model was excellent. Conclusions. Nomograms can be used by orthopaedic and trauma surgeons as a practical and effective tool in postoperative complications and mortality risk estimation

Aims. The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic. Methods. Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months. Results. There were 167 elective procedures performed in the first three weeks of the study period, prior to the first national lockdown, and 57 emergency procedures thereafter. Three patients (1.3%) were readmitted within 30 days of discharge. There was one death (0.45%) due to SARS-CoV-2 infection after an emergency procedure. None of the patients developed complications of SARS-CoV-2 infection after elective arthroplasty. There was no observed spike in complications during in-hospital stay or in the early postoperative period. There was no statistically significant difference in survival between pre-COVID-19 and peri-COVID-19 groups (p = 0.624). We observed a higher number of emergency procedures performed during the pandemic within our institute. Conclusion. An international cohort has reported 30-day mortality as 28.8% following orthopaedic procedures during the pandemic. There are currently no reports on clinical outcomes of patients treated with lower limb reconstructive surgery during the same period. While an effective vaccine is developed and widely accepted, it is very likely that SARS-CoV2 infection remains endemic. We believe that this report will help guide future restoration planning here in the UK and abroad. Cite this article: Bone Jt Open 2021;2(5):323–329

Introduction This study was conducted to quantify the incidence of gastrointestinal morbidity and identify risk factors for developing gastrointestinal morbidity following spinal surgery in children. Method A retrospective review was conducted on 253 surgical spinal procedures performed over a 5 year period at Starship Children’s Hospital. Multivariate logistic regression analysis was used to identify significant risk factors. Co-morbidity included co-existing cardiac, respiratory, genitorurinary or central nervous system problems, or delayed development. Results Seventy eight (77.9%) percent of the study population developed gastrointestinal morbidity and this significantly prolonged the median post-operative hospital stay (8 days vs.4 days; p< 0.0001). Emesis (50.6%), paralytic ileus (42.3%) and constipation (22.5%) were the most frequent gastrointestinal morbidities. Significant risk factors for developing gastrointestinal morbidity were fusion surgery (p< 0.01), co-morbidities (p-value) and duration of post-operative opioid use (p-value). Discussion There is a high incidence of gastrointestinal morbidity after paediatric spinal surgery. The consequent prolonged hospital stay has clinical implications to both the patient and the institution. We have further identified risk factors for developing gastrointestinal morbidity, of which the duration of post-operative opioid use is modifiable. Awareness of those with the other significant risk factors identified by this study could assist in the timely implementation of appropriate treatment

Aims: Bone graft substitutes have been advocated recently to avoid the potential morbidity associated with harvest of autogenous iliac crest graft. However, no commercially available graft equals autogenous bone osteo-inductive and osteoconductive qualities. We reviewed our patientsñ morbidity after harvest of 240 anterior iliac crest bone grafts for procedures involving the foot and ankle. Methods: A computerized analysis of patient records was undertaken to identify all patients under-all going a unique unicortical iliac crest bone graft harvest over a 10-year period from the senior authorñs practice. All patients were contacted either by phone or mailed questionnaire inquiring about the postoperative morbidity of the procedure. Charts were reviewed for any related complications. Results: 200 patients were available for follow-up (range 1 to 10 years). Of these patients 98% were satisþed or very satisþed with their bone graft harvest. 10 patients complained of minor residual numbness lateral to the harvest site. None complained of problems with ambulation related to graft site pain. 7% reported that their graft site pain was greater than their operative site pain during the postoperative period. 95% of patientsñ pain resolved within 4 weeks of the operative procedure. No patients incurred extra hospital days as a result of the bone graft harvest. No deep infections occurred, although there was a 6% incidence of postoperative hematoma/seroma. Conclusions: Despite common sentiment, harvesting of autogenous iliac crest bone graft yields minimal morbidity, no extra hospitalization, and optimal bone graft material at similar or lesser cost than bone graft substitutes while being overwhelmingly acceptable to patients. Bone graft substitutes may not be as cost-effective as currently thought

This study was conducted to quantify the incidence of gastrointestinal morbidity and identify risk factors for developing gastrointestinal morbidity following spinal surgery in children. A retrospective review was conducted on 253 surgical spinal procedures performed over a 5 year period at Starship Children’s Hospital. Multivariate logistic regression analysis was used to identify significant risk factors. Seventy eight (77.9%) percent of the study population developed gastrointestinal morbidity and this significantly prolonged the median post-operative hospital stay (8 days vs. 4 days; p< 0.0001). Emesis (50.6%), paralytic ileus (42.3%) and constipation (22.5%) were the most frequent gastrointestinal morbidities. Significant risk factors for developing gastrointestinal morbidity were fusion surgery, co-morbidities and duration of post-operative opioid use. The high incidence of gastrointestinal morbidity after paediatric spinal surgery and consequent prolonged hospital stay has clinical implications to both the patient and the institution. Awareness of those with significant risk factors identified by this study could assist in the timely implementation of appropriate treatment

Aims. Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. Methods. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up. Results. Immediate postoperative radiological Matta’s reduction accuracy showed anatomical reduction (0 to 1 mm) in 23 cases (67.6%), satisfactory (2 to 3 mm) in nine (26.4%), and unsatisfactory (> 3 mm) in two (6%). Merle d’Aubigné score at the end of one year was calculated to be excellent in 18 cases (52.9%), good in 11 (32.3%), fair in three (8.8%), and poor in two (5.9%). Matta’s radiological grading at the end of one year was calculated to be excellent in 16 cases (47%), good in nine (26.4%), six in fair (17.6%), and three in poor (8.8%). Merle d’Aubigné score at latest follow-up deteriorated by one point in some cases, but the grading remained the same; Matta’s radiological grading at latest follow-up also remained unchanged. Conclusion. Stabilization of posterior column through AIP by medial surface plate along the sciatic notch gives good stability to posterior column, and at the same time can avoid morbidity of the additional lateral window. Cite this article: Bone Jt Open 2024;5(2):147–153

Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition.

603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin <3.5g/dL, transferrin <200 mg/dL, or TLC <1,500 cells/mm³.

Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p<0.05). Pacific Island (p<0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European.

This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative nutritional screening and optimisation.

Introduction. Total hip arthroplasty is one of the most successful operations performed by an orthopaedic surgeon. There are three surgical approaches in use since Charnley popularised the trans-trochanteric approach. Opinion has been divided as to which approach is superior. Aim. This study was designed to examine the difference in morbidity between the classical Charnley trans-tro-chanteric approach and the antero-lateral trans-gluteal (Hardinge) approach in primary hip arthroplasty. Methods. Information on 891 patients, who underwent primary total hip arthroplasty performed by a single surgeon, was collected prospectively between 1998–2003 using a modified SF-36 form, pre-operatively, intra-operatively, and at three months. Information collected includes patient demographics, diagnosis, intra-operative blood-loss, and post-operative satisfaction and range of motion. Information was collected on the Excel database and analysed using Minitab statistical package. Results. The two groups were statistically similar for gender and side of pathology. There was no statistical difference in blood-loss between the groups. There was higher morbidity in the TT group. More patients were doubtful or dissatisfied with the THR in the TT group. There was a greater range of motion in the Hardinge group. Conclusion. In this study population, the trans-trochanteric approach was associated with higher morbidity, a lower patient satisfaction rating and a lower range of motion

The rate of litigation following personal injury is rising at an exponential rate with no concomitant rise in the actual incidence of these injuries. It is recognised that physical injury can lead to mental health disturbance and such mental health disturbance can delay recovery following injury. No previous study has assessed the incidence of pre-existing mental health morbidity amongst personal injury claimants. The general practitioners records of 750 consecutive personal injury claimants were examined. Mental health diagnoses prior to the index injury were noted and classified using the Diagnostic and Statistical Manual of the American Association of psychiatry. Any treatment by mental health professionals was noted. A highly significant excess of pre-injury psychiatric morbidity was identified in the study population. There was a 40% incidence of at least one mental health diagnosis. There was a highly significant excess of depression and anxiety. 10% of the study group had received treatment from at least one mental health professional. Pre-existing psychiatric morbidity appears to be an independent predictive factor for pursuing litigation following personal injury. In light of existing knowledge that such psychiatric morbidity often results in prolongation of physical symptoms and poor response to standard treatment regimes, it is important to recognise such patients when providing a prognosis in a medico-legal context

Aims. The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. Methods. We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. Results. There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. Conclusion. Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359–366

The Ganz trochanteric flip osteotomy has gained popularity in recent years as a surgical approach that can be used when performing debridement surgery and hip resurfacing. The advantages include preservation of blood supply to the femoral head, maintenance of abductor strength and exposure. Morbidity associated with the trochanteric osteotomy is however a problem. We reviewed the complications associated with the trochanteric flip in 367 patients that had undergone hip resurfacing arthroplasty. Pain, either felt deep within the groin or from prominent screws heads laterally was a significant problem for 96 patients (26.1%) and necessitated screw removal under general anaesthesia at a mean time of 16 months postop. Of these, 14 patients (14.5%) continued to have pain, with 8 patients proceeding to revision surgery; 5 for refractory pain, 1 for aseptic loosening, 1 for aseptic lymphocyte dominated vasculitis associated lesion (ALVAL) and 1 for acetabular soft tissue impingement. Trochanteric non-union, leading to further surgery, was diagnosed in 24 patients (6.5%) whom underwent reattachment at a mean time of 6 months postop. Within this group the majority of patients were male (16), with a mean age of 53.5 years (range 35 to 65). Trochanteric non-union was associated with smoking, diabetes, obesity, age and non-compliance. Following reattachment surgery, all patients went on to union. In total 120 patients experienced complications associated with the trochanteric osteotomy that resulted in a need for further surgery, a re-operation rate of 32.6%. Pain from trochanteric screws appears to be the over whelming issue. Surgeons using the trochanteric flip should be aware of the morbidity associated with the approach and counsel patients accordingly pre-operatively. Patients presenting with ongoing pain following screw removal should be investigated extensively for serious underlying problems

Statement of Purpose We describe the donor site morbidity of hyaline cartilage biopsy from the trochlea of the knee when used for ACI in the ankle joint. Methods We studied 12 patients who received a two stage ACI procedure on the talus, performed by three consultant surgeons. The first stage involved knee arthroscopy and harvest of cartilage for culture and stage two the transplantation of a chondrocyte culture to the ankle joint. During the first stage knee arthroscopy using a superolateral approach, the cartilage specimens were taken from a minor load bearing area of either the central or superolateral trochlea using a 5mm gouge. Clinical outcomes were assessed using a patient satisfaction score and the Lysholm knee score, taken both pre- and post- operatively at 3 months and annually thereafter. Results The mean age of the patient group was 42. The patient satisfaction questionnaires showed 11 patients to be ‘pleased’ or ‘extremely pleased’ with their ACI procedure which was sustained in the patients with up to four years follow up. The mean Lysholm score preoperatively was 98/100. Postoperatively eight patients had a reduced score (mean reduction 14) at twelve months follow up. In those patients with new knee symptoms at one year, analysis of the Lysholm score components showed the Locking and Limp categories to be the most frequent cause of a reduced score. Two patients had repeat knee arthroscopy at 18 months and 2 years postoperatively for symptoms of catching, anterior knee pain and swelling. Discussion The Lysholm knee score has components which may be affected by ipsilateral joint problems, which contribute to 20% of the overall score. However those patients with an abnormal Lysholm knee score postoperatively have gained an improved Mazur ankle score since their ACI. The procedure of cartilage harvest from the trochlea of the knee has an associated donor site morbidity which is present at one year. Ninety two percent of patients were pleased or extremely pleased with their ACI procedure, despite the requirement of surgery on their knee and it would seem that the amount of early knee morbidity these patients experience is outweighed by the improvement in symptoms in the treated joint. Ideally to optimise cartilage repair less morbid techniques to obtain cartilage need to be identified or alternatively mesenchymal stem cells could be used as an alternative source, which has already had limited success in the knee and might also be applied to other joints

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

This study aims to assess prospectively whether measurement of perioperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur. All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. 108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T >0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p<0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p<0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (7.6%) in the group with no rise (p<0.05). The principal causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment

Aims. Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population. Methods. We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria. Results. The incidence of DDH within the UK over the last 25 years is 7.3/1,000 live births with females making up 86% of the DDH population (odds ratio 6.14 (95% confidence interval 3.3 to 11.5); p < 0.001). The incidence of DDH significantly increased following the change in the Newborn and Infant Physical Examination (NIPE) guidance from 6.5/1,000 to 9.4/1,000 live births (p < 0.001). The rate of late presentation also increased following the changes to the NIPE guidance, rising from 0.7/1,000 to 1.2/1,000 live births (p < 0.001). However, despite this increase in late-presenting cases, there was no change in the rates of surgical intervention (0.8/1,000 live births; p = 0.940). Conclusion. The literature demonstrates that the implementation of a selective screening programme increased the incidence of DDH diagnosis in the UK while subsequently increasing the rates of late presentation and failing in its goal of reducing the rates of surgical intervention for DDH. Cite this article: Bone Jt Open 2023;4(8):635–642

Aim: To identify the significant risk factors that influence patient mortality and morbidity in the management of displaced subcapital neck of femur fractures in independent elderly patients (aged > 70 years) managed with total hip arthroplasty through a modified Hardinge approach. Methods: Thirty-seven primary hip arthroplasties performed for displaced fractures of the neck of femur in “Healthcare Hawkes Bay” between 1998 and 2000 were reviewed. The surgery was carried out by one surgeon (VP), using a modified lateral approach. The patients’ records were screened for outcomes and complications. An independent review was made (DA, NW) using the modified Harris hip score. Results: The average age of the patients was 85 years (range: 70 to 92 years). At an average of 1.8 years (12 months to 24 months), no patient had suffered a dislocation or had needed another operation on the hip. The majority of the patients were satisfied with the outcome. However, there were significant medical complications (total of 38 complication in 22 patients). There were two deaths in the first 12 months. Conclusions: The incidence of dislocation and a reduced revision rate can be achieved with a modified lateral approach (Hardinge). However, aggressive treatment is necessary before and after the surgery, as there is high incidence of medical complications. The number of existing medical conditions at the date of admission to hospital was a significant factor influencing patient morbidity

Background:. Morbidity of any surgical procedure is undefined. Major surgeries and minor surgeries have different morbidities but the morbidity after any surgical procedure is neither quantified nor defined in literature. Minimally invasive surgeries have evolved in all surgical branches and are known to have less morbidity after the surgery. There is no score or index to assess early recovery after any surgical procedure. Aim:. The objective of the study was to develop a scoring method to assess early post operative recovery of TKR patients. Materials and methods:. 50 consecutive total knee replacement patients were evaluated and scored at day 0, day 1, day2 and day3 post operatively. All the patients were operated upon by a single senior surgeon using minimally invasive approach. The scoring of the index consist of a questionnaire with 10 different questions regarding the general well being of the patient, wound condition, physical abilities and few other important parameters. The scores were judged from 0 to 3. Total score ranges from 0 to 30. The higher the score, the higher is the morbidity of the patient. Results:. The patients showed that the general morbidity decreases in great values from postoperative period to 24 h and 48 h after the surgery. Conclusion:. The morbidity index is a very reliable and precious way of assessing post operative condition of the patient in both surgeon's aspect and patient's aspect of view. Since there is no scoring method for early post operative assessment, this morbidity index may be important to measure the early surgical outcome of different surgeries

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. Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD. Methods. ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders. Results. A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005). Conclusion. Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity. Cite this article: Bone Joint J 2022;104-B(11):1249–1255

Aims. Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years. Methods. Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established. Results. We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery. Conclusion. Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability. Cite this article: Bone Joint J 2024;106-B(1):69–76

Aim:. To present 11 patients with quadriplegia who developed severe lordoscoliosis or hyperlordosis. This is a rare deformity in children with CP, treatment is challenging and there are less than 20 patients ever reported. Method:. All patients underwent posterior spinal arthrodesis at mean age 14.6 years with mean follow-up 3.5 years. We measured all radiographic parameters including coronal and sagittal balance and sacral slope before and after surgery. Results:. Mean preoperative lumbar lordosis was 107°. This corrected to mean 63° at follow-up. Mean preoperative thoracic kyphosis was 13°. This improved to mean 47° at follow-up. Mean preoperative scoliosis was 80°. This corrected to mean 22o at follow up. Mean preoperative pelvic obliquity was 22°. This corrected to mean 4° at follow-up. Mean preoperative sacral slope was 80o. This corrected to mean 51o at follow-up. Mean preoperative coronal imbalance was 5.2 cm. This corrected to mean 0.6 cm at follow-up. Mean preoperative sagittal imbalance was 8 cm. This corrected to mean 1.6 cm at follow-up. Mean surgical time was 260 minutes. Mean intra-operative blood loss was 0.82 EBV. Mean stay in ICU was 3.6 and in hospital 15.2 days. Complications included 3 patients with severe blood loss (1.3–2 EBV), one patient with chest and one chest and urinary infection, and a patient with superior mesenteric artery syndrome. Increased preoperative lumbar lordosis and sacral slope correlated with surgical and postoperative morbidity. In contrast, there was no correlation between preoperative scoliosis or pelvic obliquity and surgical morbidity. Reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. Greater surgical time and blood loss correlated with increased postoperative morbidity. All 11 patients and their parents reported excellent feedback on the outcome of surgery with major improvement in physical appearance, sitting balance and relief of severe preoperative back pain. Discussion:. Lordoscoliosis and hyperlordosis are associated with significant morbidity in patients with quadriplegia. The sagittal imbalance is the major component of the deformity and this can be corrected satisfactorily through a posterior spinal arthrodesis which produced excellent functional results and increased patients'/caretakers' satisfaction. Conflict Of Interest Statement: No conflict of interest

INTRODUCTION. Shoulder arthroplasty (SA) is an effective procedure for managing patients with shoulder pain secondary to degenerative joint disease or end stage arthritis that has failed conservative treatment. Insurance status has been shown to be an indicator of patient morbidity and mortality. The objective of the current study is to evaluate the effect of patient insurance status on outcomes following shoulder replacement surgery. METHODS. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing shoulder arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical and surgical complications occurring during the same hospitalization with secondary analysis of mortality. Pearson's chi¬squared test and multivariate regression were performed. RESULTS. A data inquiry identified 103,290 patients (68,578 Medicare, 27,159 private insurance, 3,544 Medicaid/uninsured, 4,009 Other) undergoing partial, total and reverse total shoulder replacements. The total number of complications was 17,810 (17.24%), and the top three complications included acute cardiac events (8,165), urinary tract infections (3,154), and pneumonia (1,635). The highest complication rate was observed in the Medicare population (20.3%), followed by the Medicaid/uninsured (16.9%), other (11.1%), and the privately-insured cohort (10.5%). Multivariate regression analysis indicated that having Medicare insurance, white race, increasing age, higher comorbidity, and urgent or emergent admissions was associated with medical complications. Black patients, increasing age and comorbities was associated with surgical complications. Overall mortality was 0.20% and was more common in total shoulder arthroplasty and surgeries done on emergent or urgent admissions. DISCUSSION. This data reveals that patients with Medicare, Medicaid or no insurance were more likely to have medical complications, most commonly cardiac complications, UTIs and pneumonia. Primary insurance payer status can be considered as an independent risk factor during preoperative risk stratification and planning

Aims. Open lower limb fracture is a life-changing injury affecting 11.5 per 100,000 adults each year, and causes significant morbidity and resource demand on trauma infrastructures. This study aims to identify what, and how, outcomes have been reported for people following open lower limb fracture over ten years. Methods. Systematic literature searches identified all clinical studies reporting outcomes for adults following open lower limb fracture between January 2009 and July 2019. All outcomes and outcome measurement instruments were extracted verbatim. An iterative process was used to group outcome terms under standardized outcome headings categorized using an outcome taxonomy. Results. A total of 532 eligible studies were identified, reporting 1,803 outcomes with 786 unique outcome terms, which collapsed to 82 standardized outcome headings. Overall 479 individual outcome measurement instruments were identified, including 298 outcome definitions, 27 patient- and 18 clinician-reported outcome measures, and six physical performance measures. The most-reported outcome was ‘bone union/healing’ reported in over 50% of included studies, while health-related quality of life was only measured in 6% of included studies. Conclusion. Outcomes reported for people recovering from open lower limb fracture are heterogeneous, liable to outcome reporting bias, and vary widely in the definitions and the measurement tools used to collect them. Outcomes likely to be important to patients, such as quality of life and measures of physical functioning, have been neglected. This systematic review identifies the need to unify outcome measures reported on patients recovering from open lower limb fracture; this may be addressed by creating a core outcome set. Cite this article: Bone Joint Res 2023;12(2):138–146

Aims. Blood transfusion and postoperative anaemia are complications of total knee arthroplasty (TKA) that are associated with substantial healthcare costs, morbidity, and mortality. There are few data from large datasets on the risk factors for these complications. Methods. We retrospectively reviewed the records of TKA patients from a single tertiary care institution from February 2016 to December 2020. There were a total of 14,901 patients in this cohort with a mean age of 67.9 years (SD 9.2), and 5,575 patients (37.4%) were male. Outcomes included perioperative blood transfusion and postoperative anaemia, defined a priori as haemoglobin level < 10 g/dl measured on the first day postoperatively. In order to establish a preoperative haemoglobin cutoff, we investigated a preoperative haemoglobin level that would limit transfusion likelihood to ≤ 1% (13 g/dl) and postoperative anaemia likelihood to 4.1%. Risk factors were assessed through multivariable Poisson regression modelling with robust error variance. Results. In multivariable analyses, each gram of tranexamic acid reduced transfusion likelihood by 39% (adjusted risk ratio (ARR) 0.61 (95% confidence interval (CI) 0.47 to 0.78)). Risk factors associated with an increased risk of transfusion included operating time (ARR 2.07 (95% CI 1.54 to 2.77)) and drain use (ARR 1.73 (95% CI 1.34 to 2.24)). Conclusion. In this study, we found that increased tranexamic acid dosing, decreased operating time, and decreased drain use may reduce transfusions following TKA. We also established a single preoperative haemoglobin cutoff of 13 g/dl that could help minimize transfusions and reduce postoperative complete blood counts. Cite this article: Bone Joint J 2023;105-B(10):1086–1093

Aims: To assess morbidity and the long term sequellae following multiple compartment syndrome of the tibia. Methods: We prospectively followed 21 referred patients (pts). Syndromeñs etiology, the socioeconomic consequences and the way the condition affects the quality of patientsñ lives were evaluated. Patientsñ morbidity, the number and the severity of the reconstructive operations were assessed. A subjective SF-36 evaluation was also performed. Results: The aetiology of the syndromes was RTA in 13 pts, accident at work in 7 and in 1 patient the result of an osteotomy and external þxation. Late release of the compartments was performed in 9 pts. In the remaining 2 pts release was performed at onset. The consequences were drop-foot in 14 pts, club foot in 2, cavus foot in 8, clawing of toes in 14, ankle stiffness in 7, plantar numbness and anesthesia in 13, plantar callosities in 5 and chronic infection in 8. Effective management involved 1–10 subsequent reconstructive procedures in the following 1 to 5 years with hospitalization ranging from 35 to 360 days. One patient was amputated. Two pts were able to perform an easy job and only those 2 in whom the compartments were released in time returned to previous occupations. The remaining are currently unemployed. Conclusions: Established compartment syndromeñs effects on soft tissue and bone seriously affect limb function, permanently impair quality of the patientñs life and deprive them from working effectively. These þndings emphasize the importance of early diagnosis and prompt release

Aims. Open lower limb fracture is life-changing, resulting in substantial morbidity and resource demand, while inconsistent outcome-reporting hampers systematic review and meta-analysis. A core outcome set establishes consensus among key stakeholders for the recommendation of a minimum set of outcomes. This study aims to define a core outcome set for adult open lower limb fracture. Methods. Candidate outcomes were identified from a previously published systematic review and a secondary thematic analysis of 25 patient interviews exploring the lived experience of recovery from open lower limb fracture. Outcomes were categorized and sequentially refined using healthcare professional and patient structured discussion groups. Consensus methods included a multi-stakeholder two-round online Delphi survey and a consensus meeting attended by a purposive sample of stakeholders, facilitated discussion, and voting using a nominal group technique. Results. Thematic analysis and systematic review identified 121 unique outcomes, reduced to 68 outcomes following structured discussion groups. Outcomes were presented to 136 participants who completed a two-round online Delphi survey. The Delphi survey resulted in 11 outcomes identified as consensus ‘in’ only. All outcomes were discussed at a consensus meeting attended by 15 patients, 14 healthcare professionals, 11 researchers, and one patient-carer. Consensus was achieved for a four-core outcome set: ‘Walking, gait and mobility’, ‘Being able to return to life roles’, ‘Pain or discomfort’, and ‘Quality of life’. Conclusion. This study used robust consensus methods to establish a core outcome set that should be measured in all future research studies and audits of clinical practice without precluding the measurement of additional outcomes. Cite this article: Bone Joint Res 2023;12(4):294–305

As our population ages, the incidence of hip fractures per annum is increasing rapidly. Within this patient group are an increasing number of very elderly (over 90 years old). These patients present many challenges to the clinician, both in terms of medical co-morbidities and orthopaedic complications. While the mortality and morbidity of hip fractures in general are well recognised, this study looked exclusively at the outcome in these very elderly patients following admission. We reviewed 100 patients admitted between May 2000 and June 2002. The average age of our patient group was 92.5 years, 18% were male and 82% female. 60% were resident in nursing homes prior to admission, 26% lived with their families and 14% lived alone in the community. 56% of the fractures suffered were intertrochanteric, 40% were intra-capsular and 4% sub-trochanteric. Following admission, these patients waited on average 1.5 days before undergoing surgery, the predominant cause for pre-operative delay being maximisation of pre-operative medical condition. Median pre-operative ASA score was three. The method of anaesthesia used was spinal in 78% and general in 22%. 64% of the group underwent internal fixation and 34% had a hemiarthroplasty. Two patients were deemed unfit to ever undergo surgery. Following surgery, mean in-hospital stay was 9.3 days. There were 8 in-patient post-operative mortalities. Major post-operative morbidities occurred in 8% and included: 3 myocardial infarctions, 2 acute onset cardiac failure and 1 prosthetic dislocation. 11% of patients required a blood transfusion. 25% of the patients died within forty days of surgery, however, 50% of the patients were still alive 126 days post-op. Overall, the mean survival was 195 days. Post-discharge morbidity included two patients who had failure of internal fixation and 8 patients with severe immobility. We conclude that hip fracture surgery in the nonagenarian population is as well tolerated as surgery in younger patients. Careful pre-operative assessment and medical maximisation combined with prompt surgical intervention yielded a good outcome and return to pre-injury status for most patients

Purpose. To compare the post-operative morbidity, of a novel vertical approach, with that of the standard transverse one, for procurement of Autologous bone graft from the iliac crest, for the purpose of cervical spine fusions. Methodology. Eighty patients undergoing procurement of bone graft from the iliac crest were prospectively randomised into two groups. The study group (36) underwent the procedure through a novel vertical approach, while the controls (44) had the standard transverse approach. Both groups were evaluated by a blinded observer at 1 month and 6 months post-operatively. The visual analogue pain score, (VAS), use of analgesics, disruption of cutaneous nerve function and local tenderness were recorded. Results. The mean VAS in the study group was 2.5 and 4.4 in the control group one month post-operatively. This was reduced to 2.9 in the control group and 1.8 in the study group six months later (p<0.05). The study group had a lower incidence of local numbness (33.3 %) compared to (72.7%) in the control group one month after surgery. Use of analgesia after 6 months was lower in the study group (11.1%), compared to 50% in the control group (p<0.05). There was no significant difference between the two groups with regards to other parameters. Conclusion. The vertical approach to the iliac crest is associated with lower morbidity and is an effective alternative to the standard approach

This study aims to assess prospectively whether measurement of peripoperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur. All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. 108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p< 0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), versus 5 (10.6%) in the group with no rise (p< 0.05). The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment

Aim: To identify the incidence of post-operative morbidity in elective total hip replacement patients as a cause for prolonged admission using the POMS. To assess the utility of POMS as a measure of short term orthopaedic outcome and a tool to influence decision making for appropriate discharge time. Background: The currently available methods for assessing overall surgical outcome (as opposed to quality of life or joint specific outcome) are generally unreliable, unvalidated, unresponsive and almost always inconsistent. Mortality is usually infrequent and length of hospital of stay is likely to be affected by non-medical factors and monitoring of complications is subject to variations in both definition and intensity of surveillance. The POMS is the only published method for prospectively describing complications associated with major surgery. It comprises a 9-point survey and provides a generic measure of short term post-operative outcome. Data is simple and quick to collect and easily learnt. No additional tests are required for data collection. Method: Patients undergoing elective primary and revision hip arthroplasty were recruited. Research assistants collected POMS data prospectively on postoperative days 1, 3, 5, 8 and 15 (if the patients were still in hospital). Results: 182 patients were recruited and followed-up. Median length of stay was 11 days (range 2–58). Of the patients remaining in hospital on post-operative days 1, 3, 5, 8 and 15, 0% (n=182), 34% (n=61), 30% (n=51), 29% (n=39) and 63% (n=22), respectively, had no evidence of medical morbidity as defined by the POMS. Conclusions: The POMS is a generic post-operative screening survey, designed to monitor morbidity in all main organ systems. This study suggests that a significant proportion of orthopaedic patients remain in hospital despite having no evidence of medical morbidity as defined by the POMS. Length of hospital stay is influenced by a number of other factors, further investigation is warranted to identify the factors responsible for their post-operative length of stay. We also hypothesize that POMS may be very useful in areas were managed care / insurance companies dictate the length of hospital stays

Aims. Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture. Methods. A systematic literature search was conducted in August 2022. ONS was defined as high protein-based diet strategies containing (or not containing) carbohydrates, fat, vitamins, and minerals. Randomized trials documenting ONS in older patients with hip fracture (aged ≥ 50 years) were included. Two reviewers evaluated study eligibility, conducted data extraction, and assessed study quality. Results. There were 812 studies identified, of which 18 studies involving 1,522 patients met the inclusion criteria. The overall meta-analysis demonstrated that ONS was associated with significantly elevated albumin levels (weighted mean difference (WMD) 1.24 (95% confidence interval (CI) 0.95 to 1.53)), as well as a significant risk reduction in infective complications (odds ratio (OR) 0.54 (95% CI 0.39 to 0.76)), pressure ulcers (OR 0.54 (95% CI 0.33 to 0.88)), and total complications (OR 0.57 (95% CI 0.42 to 0.79)). Length of hospital stay (LOS) was also significantly reduced (WMD -2.36 (95% CI -4.14 to -0.58)), particularly in rehabilitation LOS (WMD -4.17 (95% CI -7.08 to -1.26)). There was a tendency towards a lower mortality risk (OR 0.93 (95% CI 0.62 to 1.4)) and readmission (OR 0.52 (95% CI 0.16 to 1.73)), although statistical significance was not achieved (p = 0.741 and p = 0.285, respectively). The overall compliance with ONS ranged from 64.7% to 100%, but no factors influencing compliance were identified. Conclusion. This meta-analysis is the first to quantitatively demonstrate that ONS could nearly halve the risk of infective complications, pressure ulcers, total complications, as well as improve serum albumin and reduce LOS. ONS should be a regular and integrated part of the perioperative care of these patients, especially given that the compliance with ONS is acceptable. Cite this article: Bone Joint J 2023;105-B(11):1149–1158

This retrospective study compared the perioperative morbidity of two consecutive groups of patients having primary total knee arthroplasty thru subvastus approach and conventional medial parapatellar approach. The arthroplasties were performed in consecutive cases of the subvastus group(SV) (21 TKAs in 21 patients) from Dec. 1999 to May 2000 using a subvastus approach and in the control group(CY) of same operator(Y) (26 TKAs in 26 patients) from May 1999 to Nov. 1999 using medial parapatellar approach, and in the second control group(CB) (24 TKAs in 24 patients) from May 1999 to May 2000 using medial parapatellar approach by another operator (L). The patient perioperative morbidities were evaluated including blood loss, blood transfusion, lateral release, pain condition, time to ROM 90 degrees, skin complication, admission days. The subvastus group showed less time to gain 90-ROM(6.09, 6.8, 7.85), and less hospitalization days(10.43, 11.3, 12.15). But the SV group also showed higher rate of lateral release(13%, 8%, 12%) and skin complication(9%). Although the difference is not statistically significant. The authors concluded that the subvastus approach led to early ROM rehabilitation and discharge

Introduction: The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive and specific enzymatic marker of myocardial injury. This study aims to assess prospectively whether Troponin T may be used as a predictor of morbidity and mortality in admissions with fractured neck of femur. Methods: All patients aged 65 years and over presenting with a fractured neck of femur over 4 months were included. Exclusion criteria of polymyositis, renal failure and conservative fracture management were applied. Troponin T levels were measured on admission, and days 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures were defined as adverse cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. Results: 108 patients were recruited over the 4 months. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least one of the outcome complications including death, as opposed to 7 (10.6%) from the group with no Troponin rise (p< 0.001). The mean inpatient stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (10.6%) in the group with no rise (p< 0.05). Discussion: The association between raised Troponin and hip fractures has not previously been made. Many patients appear to be having silent cardiorespiratory or related events, which may be a significant cause of perioperative morbidity and mortality. We propose measurement of Troponin levels as part of the standard perioperative screening for hip fracture patients to identify this risk and initiate appropriate treatment measures

Aims. Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure. Methods. OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented. Results. Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described. Conclusion. There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: Bone Joint J 2022;104-B(5):567–574

Purpose: To compare the post-operative morbidity, of a novel vertical approach, with that of the standard transverse one, for procurement of Autologous bone graft from the iliac crest, for the purpose of cervical spine fusions. Methodology: Patients undergoing procurement of bone graft from the iliac crest were prospectively randomised into two groups. The study group (18) underwent the procedure through a novel vertical approach, while the controls (22) had the standard transverse approach. Both groups were evaluated by a blinded observer at 1 month and 6 months postoperatively. The visual analogue pain score,(VAS), use of analgesics, disruption of cutaneous nerve function and local tenderness were recorded. Results: The mean VAS in the study group was 2.5 and 4.4 in the control group one month postoperatively. This was reduced to 2.9 in the control group and 1.8 in the study group six months later. The study group had a lower incidence of local numbness (33.3 %) compared to (72.7%) in the control group one month after surgery. Use of analgesia after 6 months was lower in the study group (11.1%), compared to 50% in the control group 6 months post operatively. There was no significant difference between the two groups with regards to other parameters. Conclusion: The vertical approach to the iliac crest is associated with lower morbidity and is an effective alternative to the standard approach

The postoperative morbidity after osteosynthesis of malleolar fractures was investigated retrospectively by comparing 90 alcohol abusers with 90 controls. The two groups were selected from 626 male patients and were matched regarding trauma, treatment for cardiovascular, pulmonary and endocrine diseases, age, weight, smoking habits, anaesthesia and duration of surgery. The alcohol abusers developed significantly more early complications, especially infections, after surgery. Follow-up at six, nine and 12 weeks after surgery also revealed a significantly higher morbidity among the alcoholics

Aims. Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI. Methods. This scoping review will address three aims: firstly, to map the current extent and nature of evidence for diagnosis and management of MLKI; secondly, to summarize and disseminate existing research findings to practitioners; and thirdly, to highlight gaps in current literature. A three-step search strategy as described by accepted methodology will be employed to identify peer-reviewed literature including reviews, technical notes, opinion pieces, and original research. An initial limited search will be performed to determine suitable search terms, followed by an expanded search of four electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Web of Science). Two reviewers will independently screen identified studies for final inclusion. Dissemination. We will map key concepts and evidence, and disseminate existing research findings to the wider orthopaedic and sports medicine community, through both peer-reviewed and non-peer-reviewed literature, and conference and in-person communications. We will highlight gaps in the current literature and determine future priorities for further research. Cite this article: Bone Jt Open 2022;3(11):894–897

Aim: To compare the donor site morbidity after anterior cruciate ligament (ACL) reconstruction using ipsilateral and contralateral bone-patellar-tendon (BPT) autograft. Patients and Method: 100 patients underwent ACL- reconstruction with autologous BPT graft between 1997 and 1999. ACL-reconstruction was performed using ipsilateral (n= 52) and contralateral (n= 48) BPT-autograft. The average follow-up was 39,2 months. Donor site morbidity was evaluated by using a questionaire, computerised historical data, KT-2000 measurments, Cincinnati- (CKS) and Tegner-Score. Results: KT-2000 evaluation showed an average side to side difference of 0,6 mm in both groups. There were no significant differences between the two groups concerning CKS or Tegner-Score. In the ipsilateral donor knee, 59,6% of the patients had local tenderness, 69,2% kneeling-pain, 76,9% knee-walking-pain and 75% numbness. In the contralateral donor knee, 58,3% of the patients had local tenderness, 70,8% kneeling-pain, 70,8% knee-walking-pain and 85,4% numbness. In the ACL reconstructed knee 6,3% had local tenderness,6,3% kneeling-pain, 10,4% knee-walking-pain and 64,6% numbness. There was one rupture of the patellar tendon and one patient with chronic patellar tendinitis. Conclusion: The contralateral BPT graft appears to present no advantage over the ipsilateral as all symptoms concerning donor site morbidity are shifted from the injured into the healthy knee and return to activity is not more rapid

Introduction: In 1990 an estimated 1.3 million hip fractures occurred worldwide, a figure which is expected to double by 2025 and increase to 4.5 million by 2050. Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. A major risk factor for the development of CDAD in patients who undergo operation for fracture neck of femur is the perioperative antibiotic exposure, with cephalosporins being particularly implicated. The type ‘027’ strains of C. Difficile are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in operated fracture neck of femur patients. Material and Methods: All the patients who were diagnosed with C. Difficile after an operated fracture neck of femur at the District general hospital during the three year study period from April 2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intravenous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality. Results: A total of 1023 patients underwent surgery for fracture neck of femur during the three years of study period. The average age of the patients was 81 years. 80% of the patients were females. A total of 62 patients suffered from C. Difficile diarrhoea (6%) after the arthroplasty procedure, and within this cohort, 29 patients died during the same admission to the hospital (47%). The average length of stay for a patient with fracture neck of femur was increased from 23.4 days to 60 days in those affected with C. Difficile diarrhoea. Discussion: The patients with fracture neck of femur are generally elderly, frail and with poor body reserves. C.difficile infection in such patients not only adds to the morbidity, but also causes significant increase in the mortality rate. The broad spectrum peri-operative antibiotics used to prevent infection generally render the patient vulnerable to this highly lethal hospital bug. Introduction of simple infection control measures such as hand-washing and isolation, and change of peri-operative antibiotic protocol led to a statistically significant reduction in the incidence of C. Difficile infections after surgery for fracture neck of femur

Aims. Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs. Methods. A PROSPERO-registered systematic literature review was performed following PRISMA guidelines. All relevant studies published until January 2023 were identified. Individual outcomes and outcome measurement tools were extracted verbatim. The measurement tools were assessed for reliability and validity, and all outcomes were grouped according to the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT) filters. Results. From 91 eligible studies, 27 individual outcomes were identified, including those related to clinical assessment (n = 12), mobility (n = 4), adverse events (n = 6), investigations (n = 4), and miscellaneous (n = 1). Ten outcome measurement tools were identified, of which Hoffer’s Functional Ambulation Scale was the most commonly used. Several studies used unvalidated measurement tools originally developed for other conditions, and 26 studies developed new measurement tools. On the OMERACT filter, most outcomes reported pathophysiology and/or the impact on life. There were only six patient- or parent-reported outcomes, and none assessed the quality of life. Conclusion. The outcomes that were reported were heterogenous, lack validation and failed to incorporate patient or family perceptions. Until outcomes can be reported unequivocally, research in this area will remain limited. Our findings should guide the development of a core outcome set, which will allow consistency in the reporting of outcomes for this condition. Cite this article: Bone Joint J 2024;106-B(3):277–285

Aims. Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons. Methods. Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Results. Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group. Conclusion. The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes. Cite this article: Bone Joint J 2024;106-B(3 Supple A):10–16