Aims. This paper aims to review the evidence for patient-related factors associated with less favourable outcomes following hip arthroscopy. Methods. Literature reporting on preoperative patient-related risk factors and outcomes following hip arthroscopy were systematically identified from a computer-assisted literature search of Pubmed (Medline), Embase, and Cochrane Library using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and a scoping review. Results. Assessment of these texts yielded 101 final articles involving 90,315 hips for qualitative analysis. The most frequently reported risk factor related to a less favourable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. This was followed by female sex and patients who have low preoperative clinical scores, severe hip dysplasia, altered hip morphology (excess acetabular retroversion or excess femoral anteversion or retroversion), or a large cam deformity. Patients receiving workers’ compensation or with rheumatoid arthritis were also more likely to have a less favourable outcome after hip arthroscopy. There is evidence that obesity, smoking, drinking alcohol, and a history of mental illness may be associated with marginally less favourable outcomes after hip arthroscopy. Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes. Finally, patients who have a favourable response to local anaesthetic are more likely to have a favourable outcome after hip arthroscopy. Conclusion. Certain patient-related risk factors are associated with less favourable outcomes following hip arthroscopy. Understanding these risk factors will allow the appropriate surgical indications for hip arthroscopy to be further refined and help patients to comprehend their individual risk profile. Cite this article: Bone Joint J 2020;102-B(7):822–831

Aims. One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure. Methods. We retrospectively reviewed all repeat one-stage revision THAs performed after failed one-stage exchange THA for infection between January 2008 and December 2016. The final cohort included 32 patients. The mean follow-up after repeat one-stage exchange was 5.3 years (1.2 to 13.0). The patients with a further infection-related failure and/or all-cause revision were reported, and Kaplan-Meier survival for these endpoints determined. Patients were categorized according to the MSIS system, and its association with further infection was analyzed. Results. A total of eight repeat septic revisions (25%) developed a further infection-related failure, and the five-year infection-free survival was 81% (95% confidence interval (CI) 57 to 92). Nine (28%) underwent a further all-cause revision and the five-year all-cause revision-free survival was 74% (95% CI 52 to 88). Neither the MSIS classification of the host status (p = 0.423) nor the limb status (p = 0.366) was significantly associated with further infection-related failure. Conclusion. Repeat one-stage exchange for PJI in THA is associated with a favourable five-year infection-free and all-cause revision-free survival. Notably, the rate of infection control is encouraging when compared with the reported rates after repeat two-stage exchange. The results can be used to counsel patients and help clinicians make informed decisions about treatment. With the available number of patients, further infection-related failure was not associated with the MSIS host or limb status. Cite this article: Bone Joint J 2022;104-B(1):27–33

Purpose: Although few theatres have been equipped in France, integrated horizontal laminar airflow with air flowing in from the entire surface of one wall and flowing out through the contralateral wall is the most favourable installation for orthopaedic surgery. We had the opportunity to work in two theatres installed in 1980 with the construction of a new hospital. The objectives were to: 1) resolve the problem of airborne biocontamination of our aseptic rooms (excepting the complete isolation unit for septic patients), 2) allow intensive use of both horizontal airflow operative theatres considering the authorized budget was 2.5 aseptic rooms for 90 beds and approximately 400000 K annually (K=surgery cost-unit reimbursed by the national health insurance fund), 3) enable more favourable personnel movement and material handling than vertical flow systems where the operative surface is limited and the risk of dust accumulation is high, for indications we considered particularly important (targeted orthopaedic procedures: hip surgery for example). In addition, it appeared advisable to have repairs performed outside the operative unit, a possibility proposed with the Luwa system (Zurich, Switzerland). Material and methods: The floor surface area of each of the theatres is 34 m2 for a 99 m3 volume. One entire wall (the wall opposite the entrance for patients and surgeons) emits the horizontal laminar airflow. Air flows out through captors on the opposite wall next to the doors and is recycled. Airflow rate is greater than 0.25 m/s maintaining laminar flow throughout the theatre (anemometric measurements). The hygrometry can be controlled. Filtration removes all particles measuring 0.2 mm or larger. The temperature is maintained at 20° maximum. The entire air volume is renewed 600 times per hour. Overpressure is maintained permanently (manometric measurements) and can be controlled manually every day (first approximation). Results: 1. Aeraulic quality controls were performed by a non-specialized nurse. Intensive use was maintained for more than 15 years. Parameters were controlled after installation then every six months (during non-active periods). Essential material included a particle counter (graduated in cubic feet) which showed we were situated at a level below class 100 (Fed US 209 D). Anomalies observed several times (localised particle ascension) were related to filter dysfunctions. The ‘holes’ were eliminated by changing filters. Other parameters were maintained with no problem. The only change occurred in one of the theatres where airflow was considered to be insufficient at the end of the theatre and a defective outflow was removed; because of these changes, inflow had to be readjusted and the door occlusions had to be changed; later quality controls were favourable. Activity level was not monitored with sufficient precision to take into consideration. 2. The rate of clinical infections associated with these theatres was maintained very low but antibiotic prophylaxy was continued. Discussion: The objectives we set for these theatres have been achieved. This type of installation is very superior to vertical flow suggesting we should equip future theatres with this type of system

Aim

This study investigated the effect of the choice of antibiotic regime on outcome of patients treated for fracture-related infection (FRI) at 3 centres, in the UK and the Netherlands between 2015 and 2019.

The cause of Legg-Calve Perthes disease, 97 years after its original description remains undefined. In the present study we examined factors, which were correlated with a favourable or negative impact on the outcome of surgical treatment. From a total of 98 children, treated during the period 1994–2006, we studied 20 cases (classified as Catterall III and IV), treated surgically. The average age was 7.4 years (4–13 years). We studied in comparison the most common procedures performed: these were the varus femoral osteotomy (12) and the lateral shelf acetabuloplasty (7). The subtrochanteric osteotomy yielded superior radiological results Stuhlberg I–II (I:6, II:6), than the lateral shelf procedure Stuhlberg II–IV (II:3, III:3, IV:1). The clinical results were similar between the two groups according to the Barrett scale, excellent or good. Regarding the subtrochanteric osteotomy the most important factor was the precise varisation of the femoral neck and secondly the timing of surgical treatment early during the fragmentation stage of the disease, before the femoral head is significantly distorted. The most important positive factor regarding the lateral shelf procedure appears to be the accuracy of the surgical technique, in order that the graft coverage of the femoral head is accurately placed on the hip capsule. Negative factor for the lateral shelf procedure in one case was early weightbearing, which resulted in collapsing of the femoral head. It appears that with extensive necrosis (Caterall IV) the femoral head isn’t biomechanically enough resistant with this procedure to resist loads that result from early ambulation

Pseudoarthrosis after spinal fusion is an important complication leading to revision spine surgeries. Iliac Crest Bone Graft is considered the gold standard, but with limited availability and associated co-morbidities, spine surgeons often utilize alternative bone grafts.

Determine the non-inferiority of a novel submicron-sized needle-shaped surface biphasic calcium phosphate (BCP<µm) as compared to autograft in instrumented posterolateral spinal fusion.

Adult patients indicated for instrumented posterolateral spinal fusion of one to six levels from T10-S2 were enrolled at five participating centers. After instrumentation and preparation of the bone bed, the randomized allocation side of the graft type was disclosed. One side was grafted with 10cc of autograft per level containing a minimum of 50% iliac crest bone. The other side was grafted with 10cc of BCP<µm granules standalone (without autograft or bone marrow aspirate). In total, 71 levels were treated. Prospective follow-up included adverse events, Oswestry Disability Index (ODI), and a fine-cut Computerized Tomography (CT) at one year. Fusion was systematically scored as fused or not fused per level per side by two spine surgeons blinded for the procedure.

The first fifty patients enrolled are included in this analysis (mean age: 57 years; 60% female and 40% male). The diagnoses included deformity (56%), structural instability (28%), and instability from decompression (20%). The fusion rate determined by CT for BCP<μm was 76.1%, which compared favorably to the autograft fusion rate of 43.7%. Statistical analysis through binomial modeling showed that the odds of fusion of BCP<μm was 2.54 times higher than that of autograft. 14% of patients experienced a procedure or possible device-related severe adverse event and there were four reoperations. Oswestry Disability Index (ODI) score decreased from a mean of 46.0 (±15.0) to a mean of 31.7 (±16.9), and 52.4% of patients improved with at least 15-point decrease.

This data, aiming to determine non-inferiority of standalone BCP<μm as compared to autograft for posterior spinal fusions, is promising. Ongoing studies to increase the power of the statistics with more patients are forthcoming.

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Little information is available regarding the demographic characteristics and outcomes of patients with periprosthetic joint infection (PJI) resulting from anaerobic organisms, especially in the knee joint.

We performed a retrospective cohort analysis of all cases of knee PJI that were treated at our institution during the period from 2005 through 2012.

Anaerobes were involved in 11 (13%) of 86 first-time episodes of knee PJI, and peptostreptococcus was the most commonly isolated pathogen (10 [91%] of the 11 episodes). The average age of patients was 70 years (range, 62 to 79) and women were more than men (7 vs. 4) to develop anaerobic PJI. Of the 11 episodes of anaerobic PJI, 8 (73%) were treated with 2-stage revision arthroplasty for chronic latent infection, and 3 (27%) with parenteral antibiotics for positive intraoperative culture. Those treating with 2-stage revision arthroplasty had average 21 months prosthetic age (range, 2 to 41), and 10 weeks interim period between stages (range, 7 to 14). The overall successful rate for treating anaerobic knee PJI was 90%, and 88% for chronic latent infection.

naerobic PJI represents a substantial proportion of all occurrences of knee PJI. Treating with resection of the prosthesis and subsequent reimplantation is associated with a favorable outcome for chronic latent infection.

Locking strategies of the sliding screw in gamma nailing (G3) were tested in an experimental biomechanical study.

Twelve Composite Femoral Bone models were used. An intertrochanteric osteotomy was performed and a gamma nail was implanted in each specimen. The specimens were divided in 3 groups:

compressed and locked,

Subsequently, the specimens were investigated for cut-out patterns using digital photography and management.

All failures occurred under supraphysiological loads. During their first loading cycles, no statistical differences for stiffness and yield load were noted. Nevertheless, there was a non–significant tendency for higher failure loads for the unlocked group. Under maximum load (1100 N) and already established deformations, all Gamma Nails behaved similarly in terms of neck-screw displacement, with no statistical differences.

Unlocked screws exhibited the most moderate failure modes followed by the compressed and locked group. The third group showed the most severe failures.

In conclusion, there is evidence that sliding is biomechanically superior in gamma nailing. Despite adverse mechanical circumstances all specimens behaved satisfactorily under physiological loading

We report ten-year clinical and radiological follow-up data for the Sigma Press Fit Condylar total knee replacement system (Sigma PFC TKR). Between October 1998 and October 1999 a total of 235 consecutive PFC Sigma TKRs were carried out in 203 patients. Patients were seen at a specialist nurse-led clinic seven to ten days before admission and at six and 18 months, three, five and eight to ten years after surgery. Data were recorded prospectively at each clinic visit. Radiographs were obtained at the five- and eight- to ten-year follow-up appointments. Of the 203 patients, 147 (171 knees) were alive at ten years and 12 were lost to follow-up. A total of eight knees (3.4%) were revised, five for infection and three to change the polyethylene insert. The survival at ten years with an endpoint of revision for any reason was 95.9%, and with an endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society Score (AKSS) was 79 (10 to 99) at eight to ten years, compared with 31 (2 to 62) pre-operatively. Of 109 knee with radiographs reviewed, 47 knees had radiolucent lines but none showed evidence of loosening.

Cite this article: Bone Joint J 2013;95-B:177–80.

Aims. Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas. Methods. We collected data on 22 patients with DTC (16 follicular and six papillary carcinomas) and one patient with medullary carcinoma who underwent complete surgical resection of SMs at our institution between July 1992 and July 2017, with a minimum postoperative follow-up of five years. The cancer-specific survival (CSS) from the first spinal metastasectomy to death or the last follow-up was determined using Kaplan-Meier analysis. Potential factors associated with survival were evaluated using the log-rank test. We analyzed the clinical parameters and outcome data, including pre- and postoperative disability (Eastern Cooperative Oncology Group PS 3), lung and non-spinal bone metastases, and history of radioiodine and kinase inhibitor therapies. Results. Lung and other bone metastases at the time of surgery were observed in ten and eight patients, respectively. Three patients experienced local tumour recurrences at the operated site. The five- and ten-year CSS rates in the 22 patients with DTC were 77% and 52%, respectively. Pre- and postoperative disability and operative site tumour recurrence were identified as risk factors for short postoperative survival. Conclusion. Metastasectomy for resectable SM from DTC yielded favourable results and has the potential to improve survival. Cite this article: Bone Joint J 2023;105-B(5):575–582

Aims. We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients. Methods. A retrospective review of a prospectively collected shoulder arthroplasty database was performed between August 1991 and September 2020 to identify patients who underwent primary aTSA. Patients were excluded for preoperative diagnoses of fracture, infection, or oncological disease. Three cohorts were created based on smoking status: non-smokers, former smokers, and current smokers. Outcome scores (American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California, Los Angeles activity scale (UCLA)), range of motion (external rotation (ER), forward elevation (FE), internal rotation, abduction), and shoulder strength (ER, FE) evaluated at two- to four-year follow-up were compared between cohorts. Evaluation of revision-free survival was performed using the Kaplan-Meier method to final follow-up. Results. We included 428 primary aTSAs with a mean follow-up of 2.4 years (SD 0.6). Our cohort consisted of 251 non-smokers, 138 former smokers who quit a mean 21 years (SD 14) prior to surgery (25 pack-years (SD 22)), and 39 current smokers (23 pack-years (SD 20)). At two- to four-year follow-up, former smokers had less favourable SPADI, SST, and FE strength compared to non-smokers, and current smokers had less favourable SPADI, SST, ASES score, UCLA score, Constant-Murley score, FE, abduction, and ER strength compared to non-smokers. Non-smokers exhibited higher revision-free survival rates at two, five, eight, and ten years postoperatively compared to former smokers and current smokers, who had similar rates. Conclusion. Our study suggests that smoking has a negative effect on aTSA functional outcomes that may persist even after quitting. Cite this article: Bone Joint J 2024;106-B(11):1263–1272

Aims. Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system. Methods. A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected. Results. A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015). Conclusion. There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable. Cite this article: Bone Joint J 2023;105-B(7):751–759

Aims. Although periacetabular osteotomies are widely used for the treatment of symptomatic dysplastic hips, long-term surgical outcomes and patient-reported outcome measures (PROMs) are still unclear. Accordingly, we assessed hip survival and PROMs at 20 years after transpositional osteotomy of the acetabulum (TOA). Methods. A total of 172 hips in 159 patients who underwent TOA were followed up at a mean of 21.02 years (16.6 to 24.6) postoperatively. Kaplan-Meier analysis was used to assess survivorship with an endpoint of total hip arthroplasty (THA). PROMs included the visual analogue scale (VAS) Satisfaction, VAS Pain, Oxford Hip Score (OHS), and Forgotten Joint Score-12 (FJS-12). Thresholds for favourable outcomes for OHS (≥ 42) and FJS-12 (≥ 51) were obtained using the receiver operating characteristic curve with VAS Satisfaction ≥ 50 and VAS Pain < 20 as anchors. Results. THA was performed on 37 hips (21.5%) by the latest follow-up. Kaplan-Meier analysis indicated that the hip survival rate at 20 years was 79.7% (95% confidence interval (CI) 73.7 to 86.3). Multivariate analysis showed that preoperative Tönnis grade significantly influenced hip survival. Tönnis grades 0, 1, and 2 were associated with 20-year survival rates of 93.3% (95% CI 84.8 to 100), 86.7% (95% CI 79.8 to 94.3), and 54.8% (95% CI 41.5 to 72.3), respectively. More than 60% of the patients exhibited favourable PROMs. An advanced Tönnis grade at the latest follow-up and a higher BMI were both significantly associated with unfavourable OHS, but not with other PROMs. Conclusion. This study demonstrated the durability of TOA for hips with Tönnis grades 0 to 1 at 20 years. While the presence of advanced osteoarthritis and higher BMI was associated with lower hip functions (OHS), it was not necessarily associated with worse patient satisfaction and joint awareness. Cite this article: Bone Joint J 2022;104-B(7):767–774

Aims. This study aims to answer the following questions in patients with hip osteoarthritis (OA) who underwent total hip arthroplasty (THA): are patient-reported outcome measures (PROMs) affected by the location of the maximum severity of pain?; are PROMs affected by the presence of non-groin pain?; are PROMs affected by the severity of pain?; and are PROMs affected by the number of pain locations?. Methods. We reviewed 336 hips (305 patients) treated with THA for hip OA from December 2016 to November 2019 using pain location/severity questionnaires, modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), international Hip Outcome Tool (iHOT-12) score, and radiological analysis. Descriptive statistics, analysis of covariance (ANCOVA), and Spearman partial correlation coefficients were used. Results. There was a significant difference in iHOT-12 scores between groups experiencing the most severe pain in the groin and the trochanter (p = 0.039). Additionally, more favourable mHHS scores were related to the presence of preoperative pain in trochanter (p = 0.049), lower back (p = 0.056), lateral thigh (p = 0.034), and posterior thigh (p = 0.005). Finally, the maximum severity of preoperative pain and number of pain locations had no significant relationship with PROMs (maximum severity: HHS: p = 0.928, HOS: p = 0.163, iHOT-12 p = 0.233; number of pain locations: HHS: p = 0.211; HOS: p = 0.801; iHOT-12: p = 0.112). Conclusion. Although there was a significant difference in iHOT-12 scores between patients with the most severe pain in the groin or trochanter, and the presence of pain in the trochanter, lower back, lateral thigh, or posterior thigh was related to higher mHHS scores, the majority of preoperative pain characteristics did not have a significant impact on outcomes. Therefore, a broad array of patients with hip OA might expect similar, favourable outcomes from THA notwithstanding preoperative pain characteristics. Cite this article: Bone Jt Open 2022;3(4):332–339

Fracture related infection, in particular chronic osteomyelitis, requires complex management plans. Meta analyses and systematic reviews have not found a gold standard of treatment for this disease. In 2017 an alternative treatment protocol was undertaken in our institution; whereby staged surgery with the use of cheaply manufactured tailored antibiotic cement rods was used in the treatment of chronic osteomyelitis, secondary to traumatic long bone fractures. Short term outcomes for this protocol demonstrated a 75.7% microbiological resolution to a negative culture and a good clinical outcome of 84.2% overall was demonstrated in terms of sinus resolution, skin changes, pain and function. Our aim now was to assess the long term outcomes of this treatment strategy. A cross-sectional study of patients who had previously undergone the set treatment protocol was performed. Patient satisfaction, effects on activities of daily living, return to work and clinical improvement at 5 years following the intervention were assessed using a patient questionnaire and the validated AAOS lower limb score. The average AAOS lower limb score was 88 which was en par to other similar studies. 80% of patients had returned to some form of work. Ongoing mild pain was a persistent problem for 50% of the patients however 98% of the patients were overall satisfied with the treatment satisfaction at 5 years. Only 1 patient required further treatment. 8 patients could not be located for follow up. Chronic osteomyelitis remains a complex disease to treat. This treatment protocol demonstrates favourable microbiological, serological and clinical short term outcomes and favourable patient satisfaction and functional long term outcomes at 5 years. Our study highlights antibiotic targeted cement rods as a feasible treatment option in managing chronic osteomyelitis

Introduction. Comparative studies examining Fixed-Bearing (FB) and Mobile-Bearing (MB) Total Ankle Replacement (TAR) designs have demonstrated similar results and successful long-term outcomes for both. To date there has been no study directly comparing FB and MB designs of the same prosthesis. We present the first prospective randomised trial comparing patient satisfaction, functional outcomes and radiographic results of the Salto Talaris Fixed-Bearing and the Salto Mobile-Bearing Total Ankle Replacement in the treatment of end-stage ankle arthritis. Methods. A total of 108 adult patients with end-stage ankle arthritis were enrolled in the study between November 2014 and October 2021 with similar demographic comparison. Prospective patient-reported outcomes and standardised weightbearing ankle radiographs were performed preoperatively, at 6 weeks, 6 months and 12 months post-operatively, followed by yearly intervals. All surgeries were performed by a single non-design orthopaedic foot and ankle specialist with experience in over 200 Salto and Salto Talaris TAR prior to the study. Radiographs were examined independently by two clinicians. Complete patient data and radiographs were available for 103 patients with an average follow up of 2 years. Results. Both groups demonstrated statistically significant improvement from preoperative evaluation to most recent follow up with no statistically significant difference between the two groups in all outcome measures. Radiographic incidence of subchondral cyst formation was 8.9% and 38.2% for FB and MB, respectively. Talar subsidence occurred in 2.2% and 5.5% of FB and MB, respectively. Discussion. Our study demonstrates a higher than previously reported rate of cyst formation in the MB TAR and comparatively higher talar subsidence in the MB TAR vs FB however this did not correlate with clinical outcome measures which were favourable for both groups. Conclusion. Fixed-Bearing and Mobile-Bearing Total Ankle Replacement demonstrate comparable favourable

Survival of sepsis has been documented worldwide, but little is documented about the long-term health outcomes of multifocal sepsis from acute musculoskeletal infection - the first study of its kind in New Zealand. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1. st. January 2002 to 31. st. December 2017 with a musculoskeletal focus of infection were identified from hospital coding data. Notes review from discharge to present day determined survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed. Seventy patients were studied. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Long-term survival was favourable with no recorded deaths after discharge. Recurrence/chronic infection occurred in 23%, a mean of 1.1 year after discharge. Growth disturbance occurred in 18%, a mean of 3 years after discharge. The hip joint and proximal femur have the worst complications. Children under 2 years are most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years after discharge. Health-related quality of life scores were on par with normative data. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder. Paediatric multifocal musculoskeletal sepsis can result in complex illness with long hospital stay and multi-organ complications. Māori and Pasifika children, those under two and those involving the proximal femur/or hip are most at risk. Other outcomes are favourable with no evidence of chronic lung disease or poor quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

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

Aims. Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach. Methods. A comprehensive electronic search and quantitative data analysis from eligible studies were performed. Inclusion criteria were adults with a limb amputation managed with a one- or two-stage osseointegration procedure with follow-up reporting of complications. Results. A total of 19 studies were included: four one-stage, 14 two-stage, and one article with both one- and two-stage groups. Superficial infection was the most common complication (one-stage: 38% vs two-stage: 52%). There was a notable difference in the incidence of osteomyelitis (one-stage: nil vs two-stage: 10%) and implant failure (one-stage: 1% vs two-stage: 9%). Fracture incidence was equivocal (one-stage: 13% vs two-stage: 12%), and comparison of soft-tissue, stoma, and mechanical related complications was not possible. Conclusion. This review suggests that the one-stage approach is favourable compared to the two-stage, because the incidence of complications was slightly lower in the one-stage cohort, with a pertinent difference in the incidence of osteomyelitis and implant failure. Cite this article: Bone Jt Open 2023;4(7):539–550