Aims. Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care. Methods. Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’. Results. The least deprived cohort were older (mean 65.95 years (SD 13.33)) than the most deprived (mean 59.48 years (SD 13.85)). Mean symptom duration was lower in the least deprived areas (68.59 months (SD 112.26)) compared to the most deprived (85.85 months (SD 122.50)). Mean pain visual analogue scores (VAS) were poorer in the most compared to the least deprived cohort (7.11 (SD 2.01) vs 5.99 (SD 2.57)), with mean mood scores also poorer (6.06 (SD 2.65) vs 4.71 (SD 2.78)). The most deprived areas exhibited lower mean quality of life (QoL) scores than the least (0.37 (SD 0.30) vs 0.53 (SD 0.31)). QoL findings correlated with health VAS and Generalized Anxiety Disorder 2-item (GAD2) scores, with the most deprived areas experiencing poorer health (health VAS 50.82 (SD 26.42) vs 57.29 (SD 24.19); GAD2: 2.94 (SD 2.35) vs 1.88 (SD 2.07)). Least-deprived patients had the highest self-reported activity levels and lowest sedentary cohort, with the converse true for patients from the most deprived areas. Conclusion. The most deprived patients experience poorer physical and mental health, with this most adversely impacted by lengthy waiting list delays. Interventions to address inequalities should focus on prioritizing the most deprived. Cite this article: Bone Jt Open 2022;3(10):777–785

Aims. The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. Postal surveys were sent to 1,001 patients on the waiting list for THA or TKA in a single Northern Ireland NHS Trust, which consisted of the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee Scores. Electronic records determined prescriptions since addition to the waiting list and out-of-hour GP and emergency department attendances. Deprivation quintiles were determined by the Northern Ireland Multiple Deprivation Measure 2017 using postcodes of home addresses. Results. Overall, 707 postal surveys were returned, of which 277 (39.2%) reported negative “worse than death” EQ-5D scores and 219 (21.9%) reported the consumption of strong opioids. Those from the least deprived quintile 5 had a significantly better EQ-5D index (median 0.223 (interquartile range (IQR) -0.080 to 0.503) compared to those in the most deprived quintiles 1 (median 0.049 (IQR -0.199 to 0.242), p = 0.004), 2 (median 0.076 (IQR -0.160 to 0.277; p = 0.010), and 3 (median 0.076 (IQR-0.153 to 0.301; p = 0.010). Opioid use was significantly greater in the most deprived quintile 1 compared to all other quintiles (45/146 (30.8%) vs 174/809 (21.5%); odds ratio 1.74 (95% confidence interval 1.18 to 2.57; p = 0.005). Conclusion. More deprived patients have worse health-related quality of life and greater opioid use while waiting for THA and TKA than more affluent patients. For patients awaiting surgery, more information and alternative treatment options should be available. Cite this article: Bone Jt Open 2024;5(5):444–451

Abstract. Introduction. Knee replacement surgery can greatly improve pain, disability, quality of life and ability to work. Socioeconomic deprivation is associated with multiple poor health outcomes, partly due to reduced access to services, including surgery. We investigated whether deprivation was associated with characteristics at presentation, and outcomes following knee arthroplasty. Methodology. We linked data from 2358 knee arthroplasty cases with the Index of Multiple Deprivation, and mortality data after mean 7.6 years follow up. A locally developed scoring system was used prospectively to categorise case complexity. Results. Most patients were from more affluent areas. Deprivation was associated with younger age, and increasing case complexity. There was a significant association between case complexity and mortality, while an independent association between deprivation and mortality could not be confirmed. Conclusion. Health inequalities may impact presentations and outcomes in knee arthroplasty. Patients from areas of socioeconomic deprivation present more complex cases, which may be a result of associated comorbidity and delayed presentation due to impaired access. As knee arthroplasty can improve disability and ability to work, its availability in deprived areas can play a role in the alleviation of health inequality

Higher levels of socioeconomic deprivation have been associated with worse health outcomes. The influence of socioeconomic deprivation on patients undergoing periacetabular osteotomy (PAO) has not previously been investigated. A total of 217 patients (171 female, 46 male; median age 23.4 years) who underwent PAO by a single surgeon were identified. Patients were categorised into three groups according to their New Zealand Deprivation (NZDep) Index: minimal deprivation (NZDep Index 1–3, n=89), moderate deprivation (NZDep Index 4–6, n=94), and maximal deprivation (NZDep Index 7–10, n=34). The three groups were compared with respect to baseline variables, surgical details, complications, and pre-operative and two-year post-operative functional scores (including International Hip Outcome Tool (iHOT-12), EQ-5D quality of life score, and University of California Los Angeles (UCLA) activity score). Multivariate regression was undertaken to assess for the effect of NZDep Index on patient outcomes. Patients in the maximal deprivation group were more likely to be Māori (p<0.001) and have surgery in a public rather than a private hospital (p=0.004), while the minimal deprivation group demonstrated a lower BMI (p=0.005). There were otherwise no other significant differences in baseline variables, surgical details, complications, nor pre-operative or two-year post-operative functional scores between the three groups (all p>0.05). Multivariate analysis identified a higher NZDep Index to be independently predictive of a lower pre-operative UCLA activity score (p=0.014) and a higher two-year iHOT-12 score (p<0.001). Our results demonstrate an inequality in access to PAO, with patients exposed to higher levels of socioeconomic deprivation under-represented in our study population. When provided access to PAO, these vulnerable patients achieve significant functional improvement at least as great as patients with less socioeconomic deprivation. Initiatives to improve access to hip preservation care in socioeconomically deprived populations appear warranted

Aims. The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Methods. Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. Results. A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Conclusion. Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications. Cite this article: Bone Joint J 2024;106-B(2):174–181

We determined the impact of deprivation and frailty at the time of diagnosis of hip osteoarthritis (OA) on the likelihood of receiving total hip arthroplasty (THA). We used routinely collected primary care data (Clinical Practice Research Datalink) linked to Hospital Episode Statistics. Frailty was assessed at the time of hip OA diagnosis using a validated frailty index based on coded data in the primary care record and categorised as fit, mild, moderate, and severe frailty. The association between quintile of index of multiple deprivation (IMD), frailty category and likelihood of receiving THA was assessed in separate Cox regression models, adjusted for year of OA diagnosis, age, and sex. 104,672 individuals with hip OA contributed. Compared to those in the first quintile of IMD (least deprived), those in the fourth and fifth quintile of IMD (most deprived), respectively, were less likely to receive THA, hazard ratio (HR) (95% CI), 0.92 (0.89, 0.95) and 0.80 (0.77, 0.83). Increasing frailty at OA diagnosis was associated with reduced likelihood of receiving THA. Compared to fit individuals, the HR (95% CI) for receiving THA among those with: mild frailty was 0.80 (0.78, 0.82); moderate frailty was 0.60 (0.58, 0.62); and severe frailty was 0.42 (0.39, 0.45). Increasing deprivation was associated with increasing frailty at the time of hip OA diagnosis, independent of age, sex, and year of OA diagnosis. However, those in the two most deprived quintiles were still less likely to receive THA after additionally adjusting for frailty category. Greater deprivation and greater frailty were associated with lower likelihood of receiving THA among people with hip osteoarthritis. Greater frailty among those most deprived did not explain the reduced likelihood of receiving THA among those most deprived

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures. . We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD). . We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group. . The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived. . These findings have important implications for public health and preventative measures. . Cite this article: Bone Joint J 2015;97-B:240–5

A relationship between social deprivation and the incidence of fracture in adolescents has not previously been shown. We have used a complete fracture database to identify adolescents who sustained fractures in 2000. The 2001 Scottish census was used to obtain age-specific population and deprivation data according to the Carstairs score. Regression analysis determined the relationship between the incidence of fractures and social deprivation. We analysed 1574 adolescents with fractures (1083 male, 491 female). The incidence of fractures in this group was 21.8 per thousand (31.0 male, 13.1 female). Social deprivation predicted the incidence in adolescent males and females. The incidence of fractures of the proximal upper limb and distal radius in females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20 years of age were more likely to sustain fractures of the hand and carpus if they lived in economically depressed neighbourhoods

Introduction: The aim of this study was to determine the impact of deprivation on access to and outcome from total hip replacement in a district general setting. Methods: A prospective audit was undertaken in an elective orthopaedic centre serving an entire health region. Hip function was collected using the Harris Hip Score (HHS) Patients were followed up for a mean 71 months and the presence of complications noted. Patients were allocated a deprivation category by retrospective application of the Scottish Index of Multiple Deprivation (SIMD) quintiles. Results: A total of 2270 hip replacements were carried out in 2177 patients. There were 93 bilateral simultaneous procedures. The overall incidence of THR was 79.5/100,000 per year. This rate was significantly higher in more deprived areas. 37.4% of THRs occurred in males but there was no significant change with deprivation. Deprivation was not linked with age, length of stay or BMI. There was no association with the prevalence of diabetes, cancer, ischaemic heart disease or hypertension in this group. The incidence of smoking increased with deprivation, with a prevalence of 21.5% in the most deprived group compared to 7.7% in the least (p=0.0001). There was no observed difference in mortality, infection, dislocation, thrombosis or transfusion requirement. Preoperative and postoperative function was significantly different between groups with HHS being lower in the most deprived group compared to the least (p=0.01, p=0.005). There were ‘pockets’ of low and high incidence of THR. These correlate with the age of the population (r=0.69, p< 0.001). Conclusion: We could identify no inequality in access to total hip replacement in our centre and health board region. The incidence of smoking increased with increasing deprivation. Areas with a greater proportion of the population over 60 had an increased incidence of THR. Pre-operative function and outcomes were found to be lower in more deprived groups

Socially deprived patients face significant barriers that reduce their access to care, presenting unique challenges for orthopaedic surgeons. Few studies have investigated the outcomes of surgical fracture care among those socially deprived, despite the increased incidence of fractures, and the inequality of care received in this group. The purpose of this study was to evaluate whether social deprivation impacted the complications and subsequent management of marginalized/homeless patients following ankle fracture surgery. In this retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, we evaluated 45,444 patients who underwent open reduction internal fixation for an ankle fracture performed by 710 different surgeons between January 1, 1994, and December 31, 2011. Socioeconomic deprivation was measured for each patient according to their residential location by using the “deprivation” component of the Ontario Marginalization Index (ON-MARG). Multivariable logistic regression models were used to assess the relationship between deprivation and shorter-term outcomes within 1 year (implant removal, repeat ORIF, irrigation and debridement due to infection, and amputation). Multivariable cox proportional hazards (CPH) models were used to assess longer-term outcomes up to 20 years (ankle fusion and ankle arthroplasty). A higher level of deprivation was associated with an increased risk of I&D (quintile 5 vs. quintile 1: odds ratio (OR) 2.14, 95% confidence interval (CI), 1.25–3.67, p = 0.0054) and amputation (quintile 4 vs. quintile 1: OR 3.56, 95% CI 1.01–12.4, p = 0.0466). It was more common for less deprived patients to have their hardware removed compared to more deprived patients (quintile 5 vs. quintile 1: OR 0.822, 95% CI 0.76–0.888, p < 0.0001). There was no correlation between marginalization and subsequent revision ORIF, ankle fusion, or ankle arthroplasty. Marginalized patients are at a significantly increased risk of infection and amputation following operatively treated ankle fractures. However, these complications are still extremely rare among this group. Thus, socioeconomic deprivation should not prohibit marginalized patients from receiving operative management for unstable ankle fractures

Introduction. This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation. Patients and Methods. From a prospective database we identified and analysed all patients who had sustained a fracture of the radial head or neck over a one year period. The degree of social deprivation was assessed using the Carstairs and Morris index. The relationship between demographic data, fracture characteristics and deprivation categories was determined using statistical analysis. Results. Two hundred and ninety radial head (n=203) and neck (n=87) fractures were diagnosed with a mean age of 44.3years (13–94). There was no significant difference with regards age or gender predominance when comparing radial head and neck fractures directly. The mean age of males was significantly younger when compared to females for radial head (p<0.001) and neck (p<0.001) fractures, but with no gender predominance seen. Associated injuries (n=25) were related to increasing age (p=0.006), radial head fractures (p=0.003) and increasing fracture complexity according to the Mason classification (p<0.001). Social deprivation was related to the mean age at the time of fracture and the mechanism of injury (p<0.05 for both). Conclusions. Proximal radial fractures are frequently fragility fractures affecting older females and assessment for osteoporosis is recommended. Complex radial head fractures require thorough investigation for the presence of associated injuries

Aim: To prospectively determine whether social deprivation has an effect on the level of disability at presentation and the outcome from total knee replacement (TKR). Method: A prospective outcome study was carried out between 1992 and 1996, recruiting over 2500 total knee replacements. All patients were assessed preoperatively and at 3 and 12 months postop using the Knee Society (KS) scores for clinical evaluation and the Nottingham Health Profile (NHP) to measure general health status. The Townsend Score was used as the index of social deprivation and was calculated for each patient on the basis of their address. Results: There was no significant difference between either the Knee Society or NHP scores at baseline and the Townsend Score. This indicated that social deprivation has no effect on the level of the knee arthritis immediately prior to joint replacement, both in terms of patient disability and health status. There was also no significant difference between either the Knee Society or NHP scores postoperatively and the Townsend Score. This indicated that social deprivation has no effect on the outcome from knee replacement. Conclusion: This study shows that social deprivation has no significant effect on the level of disability at presentation and the outcome from total knee replacement. This is contrary to previously published reports which have shown worse outcomes in more deprived patients

It has been suggested that Perthes’ disease is more prevalent in urban areas, and that the risk increases with deprivation. We present the findings of a preliminary analysis of Perthes’ disease in Northern Ireland, which is shown to have one of the highest national annual rates of incidence in the world (11.6 per 100 000). Of the 313 children diagnosed over a seven-year period, 311 were allocated to the enumeration districts of the 1991 census, thus allowing the incidence to be calculated using both spatial and non-spatial aggregation. The cases were grouped according to the size of the settlement from highly urbanised to open countryside and by level of area deprivation. While the incidence of Perthes’ disease was found to be associated with indicators of the level of deprivation for areas, there was no evidence to suggest that there was an increased risk in urban areas; the highest rate was found in the most deprived rural category

Introduction. Primary cilia are organelles found singularly on almost every cell in the body, including tenocytes. Tendon is a hierarchical, composite structure, and previous work from our group has suggested that the cell populations in the inter-fascicular matrix (IFM) may be different from those within the fascicle matrix (FM). This study investigated how stress deprivation influenced the primary cilia of both cell types, and the mechanics of the IFM and the FM. Materials and Methods. Rat tail tendons were dissected and then either tested immediately (fresh), or maintained in media for 1 week, either stress deprived or at 4% static strain. Fascicles and IFM were then either, fixed and imaged to determine cilia length (n = 80–160 cilia per group from across 3 rats), or mechanically tested to determine the static and viscoelastic properties of both the fascicles and the IFM (n = 6–8 per group). Results. Cilia length in the IFM and FM of fresh samples were not significantly different. After 1 week of stress deprivation, the cilia had significantly increased in length in both the IFM and FM, however the increase in length in the IFM was significantly greater than that in the FM. Cilia in tissue maintained at 4% static strain were significantly shorter than those in stress deprived tissue, however they remained longer than those in fresh tissue. The tensile strength of the fascicles was not affected by stress deprivation or static strain conditions. However, the viscoelastic properties of the stress deprived fascicles were significantly reduced. By contrast, the tensile strength of the IFM was significantly reduced in the stress deprived samples, indicative of greater degradation in this region. Discussion. This is the first time differences in the cilia have been observed between tendon regions. Their different response to stress deprivation provides further evidence that these populations of cells respond differently to changes in mechanical stimulation. Cilia length increased more in the region where there was more mechanical degradation, suggesting that cilia are responding to their local mechanical environment

Background. Reduced bone mineral density is recognised as a risk factor for hip fractures and fragility fractures in general. Vitamin D is important in maintaining healthy bone mineral levels and can therefore affect risk of hip fracture. We investigated the correlation between vitamin D levels and bone mineral density, as well as fracture type, in neck of femur fractures and also assessed the relationship of vitamin D and social deprivation. Method. We included all patients admitted to our department, with a neck of femur fracture over one year (October 2013 to October 2014). We analysed vitamin D levels for all patients during admission and compared these to bone mineral density scores, based on DEXA scan results; hip fracture type & comminution, based on admission radiographs; and levels of social deprivation, based on the patient's address. Results. In total 360 patients were admitted over the study period, with a neck of femur fracture, of which 298 had vitamin D assessed and 76 had DEXA scans. Of these cohorts, 71% were found to be vitamin D deficient and 7% had osteoporosis. No significant correlation was found between vitamin D scores and bone density, or with level of vitamin D deficiency and fracture type or comminution. A significant correlation was however identified, between low vitamin D levels and decreasing levels of social deprivation (R=0.11, p=0.04). Conclusion. No relationship was identified between vitamin D levels and hip fracture type, suggesting that vitamin D cannot be used to predict patients at risk of more comminuted fractures. Although no relationship was also identified for bone mineral density and vitamin D, this may be because the sample size of DEXA scans was relatively small. Interestingly the relationship between vitamin D and social deprivation was the reverse of what was expected and suggests that affluent individuals may be at greater risk of low vitamin D

Standard protocol following total hip arthroplasty dictates that the hip is kept in a position of abduction until soft tissue healing is sufficient to provide stability. This is maintained by use of an abduction pillow while in bed, meaning that the patient must sleep on their back. Many patients find this position uncomfortable and have significant difficulty in sleeping. Aims: To assess the impact of sleep deprivation on recovery of the patient and quality of life in the peri-operative period. Methods: Patient cohort consisted of elective admissions for total hip replacement. All were assessed using the Epworth sleep scale, SF-36 as well as the Hospital Anxiety and depression score. Body mass index and history of insomnia or obstructive sleep apnoea were recorded. Baseline oxygen saturation was compared with postoperative overnight saturation and request for night sedation. Results: 64 consecutive patients undergoing total hip arthroplasty surgery were eligible for inclusion in the study. Mean age 68 (43 to 85), 42 females, 22 males, 62 patients were satisfied with the result of surgery, 1 patient with hip dysplasia had a persistent leg length inequality and one complained of back pain. All patients were nursed according to standard protocol with abduction pillow while in hospital and instructions to sleep on their back while at home. 18 patients did not fully comply with this instruction while at home. There were no early dislocations with a mean follow up of 5.4 months. Mean hospital anxiety and depression scores were significantly increased following surgery mean pre-operatively (5.2), to highest level (3.4) at two weeks, (8.5) at six weeks, returning to normal levels after three months (4.2). Epworth sleep scores were similarly increased with sleep patterns returning to normal at the three month stage. Increasingly, body mass index correlated significantly with poor scores and low oxygen saturation readings. This group of patients had a predisposition to obstructive sleep apnoea, which was predicated by sleeping on their backs, they require more night sedation and analgesia. Conclusions: Standard precautions following total hip arthroplasty are not without morbidity. Sleep deprivation leading to increased anxiety and decreased satisfaction. Increased demand for night sedation and analgesia with their resultant costs and dependence. Sleeping in the supine position may also precipitate obstructive sleep apnoea in at risk patients

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

Aims. This study explores the epidemiology of patients with a fracture of the scaphoid presenting to a regional teaching hospital. Patients and Methods. All patients with a confirmed fracture of the scaphoid over a retrospective period between January 2010 and May 2013 were included. Their demographics, deprivation status and when the fracture occurred was noted and assessed. There were 415 fractures in 365 males and 50 females. Results. The incidence of fracture of the scaphoid was 12.4 in 100 000 each year in the general population. The mean age of the patients was 22 years (nine to 35); the highest incidence was in males aged between 15 and 19 years. We calculate the annual incidence in the United Kingdom to be 7265 each year. Patients with the lowest socioeconomic status had an incidence of 18.57 in 100 000 whereas the least deprived patients had an incidence of 9.98 (p < 0.001). There was evidence of a seasonal trend (p = 0.022) with the highest monthly rate found in June (16.96 in 100 000 each year) and the lowest was in December (7.61 in 100 000 each year). There were significantly fewer presentations of fracture at the weekend (p <  0.001), and the highest incidence was on Mondays. Most fractures occurred at the waist (64%) and tubercle (18.1%). Take home message: In this large-scale epidemiological study, we confirmed that young men are most at risk of sustaining a fracture of the scaphoid, and report new factors in relation to social deprivation and seasonality that influence scaphoid fractures. Cite this article: Bone Joint J 2016;98-B:654–9

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. The aim of this study was to determine the long-term mortality rate, and to identify factors associated with this, following primary and revision knee arthroplasty (KA). Methods. Data from the Scottish Arthroplasty Project (1998 to 2019) were retrospectively analyzed. Patient mortality data were linked from the National Records of Scotland. Analyses were performed separately for the primary and revised KA cohorts. The standardized mortality ratio (SMR) with 95% confidence intervals (CIs) was calculated for the population at risk. Multivariable Cox proportional hazards were used to identify predictors and estimate relative mortality risks. Results. At a median 7.4 years (interquartile range (IQR) 4.0 to 11.6) follow-up, 27.8% of primary (n = 27,474/98,778) and 31.3% of revision (n = 2,611/8,343) KA patients had died. Both primary and revision cohorts had lower mortality rates than the general population (SMR 0.74 (95% CI 0.73 to 0.74); p < 0.001; SMR 0.83 (95% CI 0.80 to 0.86); p < 0.001, respectively), which persisted for 12 and eighteight years after surgery, respectively. Factors associated with increased risk of mortality after primary KA included male sex (hazard ratio (HR) 1.40 (95% CI 1.36 to 1.45)), increasing socioeconomic deprivation (HR 1.43 (95% CI 1.36 to 1.50)), inflammatory polyarthropathy (HR 1.79 (95% CI 1.68 to 1.90)), greater number of comorbidities (HR 1.59 (95% CI 1.51 to 1.68)), and periprosthetic joint infection (PJI) requiring revision (HR 1.92 (95% CI 1.57 to 2.36)) when adjusting for age. Similarly, male sex (HR 1.36 (95% CI 1.24 to 1.49)), increasing socioeconomic deprivation (HR 1.31 (95% CI 1.12 to 1.52)), inflammatory polyarthropathy (HR 1.24 (95% CI 1.12 to 1.37)), greater number of comorbidities (HR 1.64 (95% CI 1.33 to 2.01)), and revision for PJI (HR 1.35 (95% 1.18 to 1.55)) were independently associated with an increased risk of mortality following revision KA when adjusting for age. Conclusion. The SMR of patients undergoing primary and revision KA was lower than that of the general population and remained so for several years post-surgery. However, approximately one in four patients undergoing primary and one in three patients undergoing revision KA died within tenten years of surgery. Several patient and surgical factors, including PJI, were associated with the risk of mortality within ten years of primary and revision surgery. Cite this article: Bone Joint J 2022;104-B(1):45–52