Aims. It is well described that patients with bone and joint infections (BJIs) commonly experience significant functional impairment and disability. Published literature is lacking on the impact of BJIs on mental health. Therefore, the aim of this study was to assess health-related quality of life (HRQoL) and the impact on mental health in patients with BJIs. Methods. The AO Trauma Infection Registry is a prospective multinational registry. In total, 229 adult patients with long-bone BJI were enrolled between 1 November 2012 and 31 August 2017 in 18 centres from ten countries. Clinical outcome data, demographic data, and details on infections and treatments were collected. Patient-reported outcomes using the 36-Item Short-Form Health Survey questionnaire (SF-36), Parker Mobility Score, and Katz Index of Independence in Activities of Daily Living were assessed at one, six, and 12 months. The SF-36 mental component subscales were analyzed and correlated with infection characteristics and clinical outcome. Results. The SF-36 physical component summary mean at baseline was 30.9 (95% CI 29.7 to 32.0). At one month, it was unchanged (30.5; 95% CI 29.5 to 31.5; p = 0.447); it had improved statistically significantly at six months (35.5; 95% CI 34.2 to 36.7; p < 0.001) and at 12 months (37.9; 95% CI 36.4 to 39.3; p < 0.001). The SF-36 mental component summary mean at baseline was 42.5 (95% CI 40.8 to 44.2). At one month, it was unchanged (43.1; 95% CI 41.4 to 44.8; p = 0.458); it had improved statistically significantly at six months (47.1; 95% CI 45.4 to 48.7; p < 0.001) and at 12 months (46.7; 95% CI 45.0 to 48.5; p < 0.001). All mental subscales had improved by the end of the study, but mental health status remained compromised in comparison with the average USA population. Conclusion. BJIs considerably impact HRQoL, particularly mental health. Patients suffering from BJIs reported considerable limitations in their daily and social activities due to psychological problems. Impaired mental health may be explained by the chronic nature of BJIs, and therefore the mental wellbeing of these patients should be monitored closely. Cite this article: Bone Jt Open 2024;5(9):721–728

Approximately 20% of patients feel unsatisfied 12 months after primary total knee arthroplasty (TKA). Current predictive tools for TKA focus on the clinician as the intended user rather than the patient. The aim of this study is to develop a tool that can be used by patients without clinician assistance, to predict health-related quality of life (HRQoL) outcomes 12 months after total knee arthroplasty (TKA). All patients with primary TKAs for osteoarthritis between 2012 and 2019 at a tertiary institutional registry were analysed. The predictive outcome was improvement in Veterans-RAND 12 utility score at 12 months after surgery. Potential predictors included patient demographics, co-morbidities, and patient reported outcome scores at baseline. Logistic regression and three machine learning algorithms were used. Models were evaluated using both discrimination and calibration metrics. Predictive outcomes were categorised into deciles from 1 being the least likely to improve to 10 being the most likely to improve. 3703 eligible patients were included in the analysis. The logistic regression model performed the best in out-of-sample evaluation for both discrimination (AUC = 0.712) and calibration (gradient = 1.176, intercept = -0.116, Brier score = 0.201) metrics. Machine learning algorithms were not superior to logistic regression in any performance metric. Patients in the lowest decile (1) had a 29% probability for improvement and patients in the highest decile (10) had an 86% probability for improvement. Logistic regression outperformed machine learning algorithms in this study. The final model performed well enough with calibration metrics to accurately predict improvement after TKA using deciles. An ongoing randomised controlled trial (ACTRN12622000072718) is evaluating the effect of this tool on patient willingness for surgery. Full results of this trial are expected to be available by April 2023. A free-to-use online version of the tool is available at . smartchoice.org.au.

The patient's subjective experience of disease is an increasing focus in health care delivery. Health-related quality of life (HRQoL) is defined as a “functional effect of a medical condition and its consequent treatment”; it is both self-reported and multi-dimensional. While functional outcome is well researched among the soft tissue sarcoma (STS) population, few studies have focused on HRQoL, which gives a broader understanding of the psychological, somatic, social and physical toll of cancer and its treatment from the patient's viewpoint. The biologic and anatomic heterogeneity of sarcomas are considerable, just as the treatments are diverse, we surmise that the indicators of patient HRQoL differ and are not captured in existing generic HRQoL tools for cancer. The study objectives were to explore the domains of HRQoL and functioning in adult patients diagnosed with extremity STS from the patient's perspective from active care through survivorship through qualitative inquiry, so as to form the basis for the development of a patient-derived, sarcoma-specific, preference based HRQoL tool. Study design is a sequential exploratory mixed methods study of patient experience in localized or metastatic adult extremity STS (2007 and 2017). The study was conducted at a high-volume sarcoma centre. Qualitative descriptive design was grounded in an integrated knowledge translation approach and aimed at identifying HRQoL domains through in-person and electronic focus groups, and individual semi-structured interviews in both English and French (N=28). The interview guide topics were selected based on existing knowledge about PROs and HRQoL life, including (a) impact of diagnosis on employment or acquisition of academic/vocational skills; (b) physical and psychological functioning; (c) symptom burden; (d) treatment preferences; (e) knowledge of and use of existing resources; (f) impact on family time and resources; and (g) overall experience. Data was analyzed using inductive thematic networks approach using the qualitative software N-Vivo 12. Codes were generated by 2 independent qualitative experts capturing key concepts of HRQoL that is impacted by STS. Basic themes were clustered into organizing themes, and merged into global domains. Attention was paid to deviant cases and within-group dynamics during focus group discussion analysis. Discrepancies or inconsistencies in coding were resolved in consensus meetings. Final sample size was determined when data saturation was reached and no new themes emerged. Qualitative reduction of identified items to reach a consensus framework was facilitated by a moderator during multi-disciplinary panel meetings comprised of sarcoma experts, patient partners, allied health staff and other stakeholders. Twenty-nine patients with biopsy-proven localized or metastatic STS of the extremity participated (69% lower extremity STS; mean age 56 years, 25% with local recurrence, 21% metastatic, 18% amputation). Inductive thematic network analysis revealed five function-related domains HRQoL for patients with STS. The functional domains were mapped to the Wilson & Cleary Model and experience domains were mapped to the Picker Institute's Through Patient's Eyes model. This is a critical step toward developing disease specific outcome measures. Patient-centered research is crucial to understanding the impact of surgery, adjuvant therapy and the associated complications for patients with extremity STS, and thereby improving the quality of care provision. This study offers a unique perspective on what domains and sub domains are most impactful on HRQoL and provides the basis for our on-going development of a disease-specific, preference-based HRQoL measure

Periprosthetic joint infection is a significant complication of total hip arthroplasty. The PRSThesis of Antibiotic Loaded Acrylic Cement (PROSTALAC) system can improve health related quality of life during a two step treatment approach for infection resolution. We investigated quality of life with the PROSTALAC in situ and also compared subjects who underwent second stage surgery with those who retained the PROSTALAC on a long term basis.

Twenty nine subjects were enrolled pre-PROSTALAC insertion, recording demographics, physical demand level and comorbidities. Subjects were then followed out to 24 months with either the PROSTALAC in situ or post revision for those who underwent the second stage surgery. Quality of life was evaluated using the Western Ontario McMaster Osteoarthritis Index (WOMAC) and RAND 36-Item Health Survey (RAND-36). Infection resolution was also determined for all subjects enrolled.

Three subjects died and 22/26 (84%) completed the evaluation. Overall 26 (85%) infections resolved. Following PROSTALAC insertion, WOMAC pain and function scores improved within three to six months and did not change out to 24 months. Physical function, bodily pain and vitality also significantly improved within three to six months postoperatively. Only seven (32%) subjects underwent second stage surgery. These individuals were more likely to be high demand (p=0.03) and trended towards being younger, male, with fewer comorbidities and lower BMI (p<0.10). There was no difference in WOMAC scores at 24 months between those who underwent second stage revisions and those who retained the PROSTALAC.

The use of a PROSTALAC implant improves health related quality of life. Long term retention of the PROSTALAC implant may be appropriate for low demand patients and considered for potentially high risk surgical candidates.

Worldwide, it is expected that 6.3 million patients will sustain a hip fracture in 2050. Hemiarthroplasty is commonly practiced for displaced femoral neck fractures. The choice between unipolar (UH) or bipolar (BH) hemiarthroplasty is still controversial. The objective of this study was to assess the effect on hip function of BH compared to UH for a displaced femoral neck fracture in elderly patients. We conducted a systematic review and meta-analysis of randomized controlled trials comparing BH to UH. Data sources were Medline, Embase, Cochrane Library and Web of Science. All data was pooled in Review Manager (RevMan) version 5.3 software. Selection of the studies included, data abstraction, data synthesis, risk of biais and quality of evidence evaluation was done independently by two authors. Our primary outcome was postoperative hip function. Secondary outcomes were health-related quality of life (HRQoL), acetabular erosion and postoperative complications. 13 randomized controlled trials (n=2256) were eligible for the meta-analysis. There was no difference in hip function scores (standardized mean difference of 0.33 [−0.09–0.75, n=864, I. 2. = 87%,]). Patients with bipolar heads had higher Health-Related Quality of Life scores than patients with unipolar heads (mean difference in EQ-5D scores of 0.12 [0.04–0.19, n=550, I. 2. = 44%]). The use of BH decreased the incidence of acetabular erosion (relative risk of 0.37 [0.17–0.83, n=525, I. 2. = 0%]). There was no relative risk difference for mortality, dislocation, revision and infection. Due to the high heterogeneity between the studies included, it is still unclear whether patients undergoing BH have better hip function than patients undergoing UH. Although, health-related quality of life (HRQoL) may be improved. Future research could be conducted to determine whether a BH offers a better quality of life than UH to geriatric patients undergoing surgery. More precise assessment scores could be developed to better evaluate postoperative outcomes

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

This study aimed to identify long-term physical and psychosocial health outcomes in children with overwhelming musculoskeletal sepsis. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1st January 2002 to 31st December 2017 with a musculoskeletal focus of infection were identified. A medical notes review was completed to determine 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. 70 patients were identified over 15 years. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Recurrence/chronic infection affected 23%. Growth disturbance affected 18%. The hip joint and proximal femur suffered the worst long-term complications. Children under 2 years 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 acquired brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years (SD 4.5, range 2– 18 years) after discharge. Health-related quality of life scores were on par with normative data. All patients who underwent pulmonary function tests had normal results. 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 multi-organ complications for some children. Māori and Pasifika children are most at risk. Children under 2 years and those with proximal femur and/or hip involvement are most likely to have chronic musculoskeletal sequelae and permanent disability. Other outcomes are favourable with no evidence of chronic lung disease or mean reduced quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

Significance. Increasing health care costs are bankrupting the United States and other industrialized countries. To control and/or reduce costs in health care, hospitals, payers, and patients are turning to evidence-based meta-analyses and health economic analyses to identify medical treatments that provide value (value=outcome/cost). Objective: To determine if clinical outcome (patient reported outcomes) analyses or value/economic analyses are more likely to provide the evidence needed for adoption of new technologies in arthroplasty. Methods. A proprietary joint arthroplasty database of patient reported outcomes (PROs) was analyzed to determine the minimum clinically important differences (MCIDs) for PROs used for total knee replacement surgery. The PROs analyzed were: (1) European quality of life (EQ-5D); Oxford Knee Score (OKS); (3) Lower Extremity Activity Scale (LEAS); and (4) Likert Pain Scale (LPS). The MCID was calculated using a distribution method where the MCID equals one half the standard deviation of the score change, MCID = σΔ/2. For clinical meta-analyses, new technologies must demonstrate statistically significant better PROs and the difference must be greater than the MCID. For economic analyses, quality adjusted life years (QALYs) are used. For example, if a total knee replacement (TKR) improved a patient's health-related quality of life by 10% (0.10) and the assumed implant life is 15 years, the patient received 1.5 QALYs (0.10 × 15 years). If the total cost of care for the knee replacement surgery is $30,000, the cost per QALY is $20,000 ($30,000/1.5 QALYs). Results. The MCIDs for EQ-5D, OKS, LEAS, and LPS are 0.086%, 4.6 points, 1.6 points, and 1.3 points, respectively. The mean change (one-year post-operative EQ-5D minus pre-operative EQ-5D) for health-related quality of life is 15% (0.15). The average patient received 2.25 QALYs (0.15 × 15 years) from the surgery. The average cost per QALY is $13,333. However, if a new technology improves the mean health-related quality of life by 1% and the assumed implant life is 15 years, the patient receives 0.15 QALYs of improvement. With an average cost per QALY of $13,333, the new technology will be cost effective if the new technology cost is less than or equal to $2,000 (0.15 × $13,333) per patient. Conclusions. Achieving clinical superiority with new arthroplasty technology will be difficult because the minimum clinically important differences that need to be achieved are significant (EQ-5D 8.6%, OKS 4.6 points, LEAS 1.3 points, and LPS 1.3 points). However, small mean improvements in health-related quality of life (1%) can make the new technology cost effective. New technologies for arthroplasty surgery will increasingly need economic analyses to demonstrate cost effectiveness. Orthopaedic surgeons and manufacturers must collaborate to routinely collect health-related quality of life (EQ-5D) patient reported outcomes to provide a pathway for adoption of new innovative arthroplasty technologies

Acute Haematogenous Osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Previous research on sequelae from AHO rarely considers outcomes more than two years following treatment. This study aims to establish the quality of life of patients diagnosed with AHO in childhood up to 13 years after diagnosis, evaluating the impact on social, emotional, physical, and school function. Children treated for AHO between 2008–2018 at a tertiary referral centre in New Zealand were identified. PedsQL™ questionnaires were conducted via phone with either the child or primary caregiver and responses analysed. 40 patients met inclusion criteria, were contactable by phone, and consented to participate. The mean age was 7 years (range 0–15) and most were female (60%). Health related quality of life (HRQOL) was scored as a percentage with most participants scoring >80% (n=27). Those who do experience reduced quality of life following treatment for AHO were likely to complain of pain, stiffness, or anxiety. The impact of significant childhood illness on mental health was not adequately captured by the PedsQL™ but was highlighted in qualitative feedback. We conclude that the majority of children treated for AHO reported excellent health-related quality of life up to 13 years following treatment although an negative impact on mental health was reported using qualitative analysis. A refined scoring system is needed to assess the long-term impact of musculoskeletal infection

The aim of this study was to determine the floor and ceiling effects for both the QuickDASH and PRWE following a fracture of the distal radius. Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and if there were patient factors associated with achieving a floor or ceiling effect. A retrospective cohort study of patients sustaining a distal radius fracture and managed at the study centre during a single year was undertaken. Outcome measures included the QuickDASH, the PRWE, EuroQol-5 Dimension-3 Levels (EQ-5D-3L), and the normal wrist score. There were 526 patients with a mean age of 65yrs (20–95) and 421 (77%) were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs (4.3–5.5). A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the minimum clinical important difference of the best available score, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients that achieved a ceiling score for the QuickDASH and PRWE subjectively felt their wrist was only 91% and 92% normal, respectively. On logistic regression analysis, a dominant hand injury and better health-related quality of life were the common factors associated with achieving a ceiling score for both the QuickDASH and PRWE (all p<0.05). The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of fractures of the distal radius. Patients achieving ceiling scores did not consider their wrist to be ‘normal’. Future patient-reported outcome assessment tools for fractures of the distal radius should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score

Background:. Hip arthroplasty is very successful in order to alleviate pain and improve health-related quality of life. Health-care costs are constantly growing and the burden of patients with hip disease has increased dramatically. Careful consideration of the patients'need and expectations include not only the proper indication for surgery but also choice of method. Hip resurfacing (HRA) has been popularized during the last decade, being bone conservative, capable to restore the anatomical hip center and lower the risk of dislocation. Some HRA-designs have proven good long-term survival rate while others have shown an unacceptable high amount of loosening and been recalled. Yet, for a selected group of patients HRA may be advantageous to THA regarding health-related quality of life. A fundamental prerequisite understanding today's and tomorrow's request on hip arthroplasty is to measure outcomes from patients' perspectives. In this pilot study we compared the patient-reported outcome measures after hip resurfacing with THA using validated general and hip disease specific instruments. Methods:. A questionnaire was sent to 108 randomly selected patients (72% male) of a cohort of 259 patients (Charnley A+B) who had had uni- or bilateral (two stages) HRA for a period of at least six months. Maximal follow-up time was 7 years. Mean age was 50.2 years (males) and 46.2 years (females) respectively. Patients were reporting EQ-5D and self assessed health-quality (0–100%). In addition, a minor group randomly selected, reported their activity that was graded according to UCLA-activity score. As preoperative EQ-5D baseline, a matched group of 40 patients from the hospital's database scheduled for HRA served. Results:. 92 of 108 questionnaires with EQ-5D and self assessed health quality were complete. The mean postoperative EQ-5D was 0.89 (0.30 preoperative) and self assessed health quality being 59.3% (15–100) preoperatively was 80.2% (40–100) postoperatively. UCLA- activity score was 7.2 (4–9) postoperative. Of the whole group of 259 patients, three patients suffered from nerve palsy (two transient), two early cupmigrations (revised), one psoas-impingement and one AVN with cervical fracture (both revised), one deep infection, one ALTR and one dislocation (high-energy trauma). Conclusion:. Traditional outcome measures often fail to describe outcome from the patients' perspectives. This pilot study, with its limitations, shows that patients' health-related quality of life, as measured with EQ-5D after HRA is comparable to or better than that of THA. Patients with HRA in general seem to reach high activity level. However, adverse reactions to metal debris are escalating and with HRA compared to proven THA-designs the risk of complications, e.g., early loosening, especially in females, is higher. For men, no significant difference in survival rate is reported for HRA compared to THA. Yet, HRA should be considered in subgroups of patients (younger, active men), in order to gain high patient satisfaction

Avulsion of the proximal hamstring tendon from the ischial tuberosity is an uncommon but significant injury. Recent literature has highlighted that functional results are superior with surgical repair over non-surgical treatment. Limited data exists regarding the optimal rehabilitation regime in post-operative patients. The aim of this study was to investigate the early interim patient outcomes following repair of proximal hamstring tendon avulsions between a traditionally conservative versus an accelerated rehabilitation regimen. In this prospective randomised controlled trial (RCT) 50 patients underwent proximal hamstring tendon avulsion repair, and were randomised to either a braced, partial weight-bearing (PWB) rehabilitation regime (CR = 25) or an accelerated, unbraced, immediate full weight-bearing (FWB) regime (AR group; n = 25). Patients were evaluated preoperatively and at 3 months after surgery, using the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT), visual analog pain scale (VASP), Tegner score, and 12-item Short Survey Form (SF-12). Patients also filled in a diary questioning postoperative pain at rest from Day 2, until week 6 after surgery. Primary analysis was by per protocol and based on linear mixed models. Both groups, with respect to patient and characteristics were matched at baseline. Over three months, five complications were reported (AR = 3, CR = 2). At 3 months post-surgery, significant improvements (p<0.001) were observed in both groups for all outcomes except the SF-12 MCS (P = 0.623) and the Tegner (P = 0.119). There were no significant between-group differences from baseline to 3 months for any outcomes, except for the SF-12 PCS, which showed significant effects favouring the AR regime (effect size [ES], 0.76; 95% CI, 1.2-13.2; P = .02). Early outcomes in an accelerated rehabilitation regimen following surgical repair of proximal hamstring tendon avulsions, was comparable to a traditionally conservative rehabilitation pathway, and resulted in better physical health-related quality of life scores at 3 months post-surgery. Further long term follow up and functional assessment planned as part of this study

Aim. External fixator knee arthrodesis is a salvage procedure mainly used in cases of end-stage infected total knee replacement (iTKR). A stable fixation combined with bone-ends compression is basic to achieve knee fusion in such a scenario but providing enough stability can be challenging in the presence of severe bone loss after multiple previous procedures. Compared with monoplanar configuration, a biplanar frame achieves improved coronal stiffness, while providing the advantages of good access to the wound and allowance of early ambulation. Our primary hypothesis stated that a biplanar frame would achieve higher and quicker fusion rate than a monolateral configuration. Method. We conducted a retrospective cohort study examining patients managed with biplanar external fixator knee fusion due to non-revisable iTKR between 2014 and 2018. We compared this group of patients with a historical cohort-control patient who had been previously published by our unit in 2013, since we switched from a monoplanar to a biplanar configuration for the management of this kind of complex end-stage iTKR. Primary end-points were fusion rate, time to achieve bone fusion and infection eradication rate. Limb-length discrepancy, pain level, patient satisfaction, and health-related quality of life were also evaluated. Results. A total of 29 cases were finally included; 8 patients were managed with a bilateral external fixator and 21 patients were managed with a monoplanar external fixator. In the biplanar configuration group, infection was eradicated in 100% of the patients, and fusion was achieved in all cases after 5.24 months on average. In comparison, in the monolateral configuration group, infection was eradicated in 18 (86%) out of 21, whereas fusion was achieved in 17 (81%) of the patients after a mean of 10.3 months (range, 4–16). Such difference was statistically significant (p<0.05). In both groups, postoperative pain was mild (VAS score 2,25 and 3,4, respectively) and patients expressed a high degree of satisfaction once fusion was achieved. Conclusions. External fixation knee fusion is a useful limb-salvage procedure in end-stage cases of knee PJI. According to our data, the use of a biplanar configuration allows us to reduce in half (10.3 vs 5.2 months, p<0.05) the time needed to achieve the solid bone fusion in such a complex scenario. In this cohort of previously multi-operated patients, the satisfaction is high, and the level of pain is low if a solid bone fusion free of infection is achieved

Introduction. The Accolade II taper stem incorporates design features which maximize proximal stem fit and bone contact and avoids more distal taper engagement which has been shown to be problematic. RSA was used in this study to analyze stem micromotion to 2 years post-surgery, providing an indication of long-term fixation. Pain, function and health-related quality of life were also compared before and after total hip arthroplasty (THA.). Method. This prospective, single centre case-series enrolled 35 patients into Parts A and B. The first 5 subjects were recruited to Part A of the study (learning curve), the subsequent 30 patients to part B. Radiopaque tantalum beads were inserted intra-operatively into each patient, with RSA radiographs taken immediately post-operatively, and at 3, 6, 12 and 24 months. These radiographs were digitized to DICOM file format and exported, allowing for independent analysis using the UmRSA system. Three Patient Reported Outcome Measurements; WOMAC, EQ-5D-3L and VAS pain were collected pre-operatively and at 6, 12 and 24 month intervals for all patients. Results. A total of 33 patients completed the study, with 1 patient from Part A lost to follow up and 1 patient from part B withdrawing voluntarily. The 4 completed patients from part A of the study did not have RSA X-rays analysed since Part A was included for surgeon training purposes only. Hence RSA X-rays at the 2 year timepoint for 29 completed Part B patients were compared to immediate post-op RSA X-rays. The Average Maximum Total Point Motion (MTPM) of the Accolade II femoral stem was 0.764mm (SD +/− 0.340), with a clinical precision (defined as the standard deviation of double RSA examinations taken during the post-operative interval) of +/− 0.195mm. Additionally, the mean distal, medial and posterior migrations for the 29 patients at 24 months were all less than 0.1mm. When comparing with the literature, these MTPM values show less than average stem migration. A systematic review conducted by de Vries et al (2014) recorded 2 year MTPM values between 0.66 and 2.73mm for clinically successful uncemented collarless stems, with an average of 1.50mm. The average WOMAC and VAS pain scores for 33 completed patients from parts A and B demonstrated decreased pain and functional limitations at 24 months when compared with pre-operative PROM results. In addition, average UK Time Trade-Off scores calculated from the EQ-5D-3L improved from 0.47 (SD +/− 0.29) pre-operatively to 0.86 (SD +/− 0.27) at 24 months, equating to improved health-related quality of life for all patients. Conclusions. The mean MTPM from this study falls well below the average for uncemented collarless stems suggested by de Vries et al (2014). This, together with the negligible distal stem migration, affirms excellent immediate stability of the Accolade II design. These RSA results imply successful biologic fixation and a high survival rate can be expected with the Accolade II stem

Instrumented fusion for lumbar degenerative spondylolisthesis (LDS) has been challenged recently with high impact trials demonstrating similar changes in health-related quality of life (HRQOL) and less morbidity/cost with laminectomy alone. Randomized trials often fail, however, to evaluate a heterogeneous population of patients. A standardized clinical assessment and management plan (SCAMP) was created as a decision aid for surgeons based on the radiographic stability and clinical presentation of patients. The purpose of this study was to compare outcomes of those patients who followed the decision aid with respect to fusion/no fusion to those who did not. Patients were prospectively enrolled from eleven different Canadian institutions and followed from 2015–2019. A degenerative spondylolisthesis instability classification system (DSIC) was created using best available evidence stratifying patients into three different subtypes (1. stable degenerative spondylolisthesis, 2. potentially unstable spondylolisthesis and 3. unstable spondylolisthesis). The decision aid recommends laminectomy alone for group 1 patients, posterolateral fusion with pedicle screws in type 2 patients and pedicle screw and interbody fusion for type 3 patients. One year changes in HRQOL, length of hospital stay (LOS), medication use and surgical time were compared between each group and in context of whether the treatment fell within the decision aid recommendation. Statistics were performed with STATA software. There were 394 patients initially enrolled and 334 (84.8%) with full one year data available for comparison. There were 95 type 1 (stable), 224 type 2 (potentially unstable) and 75 type 3 (unstable) patients initially classified. Baseline Ostwestry disability index (ODI), EQ-5D, and SF-12 MCS scores were significantly worse for type 3 patients versus type 1 patients. One hundred and eight patients were treated within the recommendations of the DSIC system (108/334, 32.3%). Surgeons performed interbody fusions in 141 patients (42%) rather than follow DSIC recommending a less invasive approach. There were no significant differences EQ-5D, SF-12 PCS/MCS, PHQ-9 or ODI at one year between patient groups. There was a trend towards shorter operating times for those patients following the DSIC system (195 minutes non-followers versus 180 followers, p=0.078) and reduced hospital stay (4.46 days non-followers versus 3.98 followers, p=0.065). There were no significant clinical differences in outcome at 1 year whether patients underwent decompression alone, decompression/posterolateral fusion or interbody fusion regardless of the stability classification. Surgeons were more likely to perform potentially unnecessary interbody fusions even in those patients with stable or potentially unstable spondylolisthesis. Although not statistically significant, there is some suggestion that following the DSIC system based on best evidence recommendations leads to more judicious/responsible use of hospital resources. Further study is required to determine why surgeons are more likely to choose more invasive, higher rigidity constructs in patients with LDS

Displaced femoral neck fractures can have devastating impacts on quality of life and patient function. Evidence for optimal surgical approach is far from definitive. The Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) trial aimed to evaluate unplanned secondary procedures following total hip arthroplasty (THA) versus hemi-arthroplasty (HA) within two years of initial surgery for displaced femoral neck fractures. Secondary objectives evaluated differences in patient function, health-related quality of life, mortality, and hip-related complications HEALTH is a large randomized controlled trial that included 1,495 patients across 81 centers in 10 countries. Patients aged 50 years or older with displaced femoral neck fractures received either THA or HA. Participants were followed for 24 months post-fracture and a Central Adjudication Committee adjudicated fracture eligibility, technical placement of prosthesis, additional surgical procedures, hip-related complications, and mortality. The primary analyses were a Cox proportional hazards model with time to the primary study endpoint as the outcome and THA versus HA as the independent variable. Using multi-level linear models with three levels (centre, patient, and time), with patient and centre entered as random effects, the effect of THA versus HA on quality of life (Short Form-12 (SF-12) and EQ-5D), function (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), and mobility (Timed Up and Go Test (TUG)) were estimated separately. The majority of patients were female (70.1%), 70 years of age or older (80.2%), and able to ambulate without the aid of an assistive device before their fracture (74.4%), and the injury in the majority of the patients was a subcapital femoral neck fracture (61.9%). The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to THA and 60 of 723 patients (8.3%) who were randomly assigned to HA (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; p=0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemi- arthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total WOMAC total score, pain score, stiffness score, and function score, modestly favored THA over HA. Mortality was similar in the two treatment groups (14.3% among the patients assigned to THA and 13.1% among those assigned to HA, p=0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to THA and in 265 patients (36.7%) assigned to HA. Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo THA and those who were assigned to undergo HA, and THA provided a clinically unimportant improvement over HA in function and quality of life over 24 months

The primary aim of this study was to identify the rate of osteoarthritis in scaphoid fracture non-union. We also aimed to investigate whether the incidence of osteoarthritis correlates with the duration of non-union(interval), and to identify the variables that influence the outcome. We retrospectively reviewed 273 scaphoid fracture non-union presented between 2007 and 2016. Data included patient demographics, interval, fracture morphology, grade of osteoarthritis (Kellgren-Lawrence) and scaphoid non-union advanced collapse (SNAC), and overall health-related quality of life. Patients were divided into two groups (SNAC and Non-SNAC). Group differences were analysed using Mann-Whitney U test and association with Pearson's correlations. A two-sided p-value of <0.05 was considered significant. The scaphoid fracture non-union were confirmed on CT scans (n=243) and plain radiographs (n=35). The subjects were 32 females and 260 males with the mean age of 33.8 years (SD, 13.2). The average interval was 3.1 years (range, 0–45 years). Osteoarthritis occurred in 58% (n=161) of non-unions, and 42% (n=117) had no osteoarthritis. In overall, 38.5% (n=107) had SNAC-1, 9% (n=25) with SNAC-2, and 10.4% (n=29) presented with SNAC-3. The mean interval in the non-SNAC group was 1.2 years, and in SNAC 1,2, and 3 were 2.6, 6.8, and 11.1 years, respectively. The average summary index in SNAC and non- SNAC groups was 0.803 and 0.819, respectively. Our results also showed a significant correlation between advanced osteoarthritis and proximal fracture non-unions(P<0.05). We concluded that there is no clear correlation between the interval and the progression of osteoarthritis. SNAC was more likely to occur in fractures aged 2 years or older

Negative pressure wound therapy (NPWT) is commonly used to manage severe open fracture wounds. The recently completed X randomized controlled trial (RCT) evaluated the effect of NPWT versus standard wound management on 12-month disability and rate of deep infection among patients with severe open fractures of the lower limb and reported no differences. Using data from the Y trial of open fracture patients, we aimed to evaluate the impact of NPWT on the odds of having deep infections and health-related quality of life (HRQL). Our analyses included participants from the Y trial who had Gustilo II and III lower extremity fractures. To adjust for the influence of injury characteristics on type of dressing received, a propensity score was developed from the dataset. A one-to-one matching algorithm was then used to pair patients with a similar propensity for NPWT. Mixed effects logistic regression was used to evaluate the association between type of wound dressing and development of a deep infection requiring operative management (dependent variable) in the matched cohort. Gustilo type, irrigation solution, fracture location, mechanism of injury, and degree of contamination were included as adjustment variables. To determine any differences in HRQL between the NPWT and standard wound dressing groups, we conducted two multi-level models with three levels (centre, patient, and time) and included Short Form-12 (SF-12) Physical Health Component (PCS) and SF-12 Mental Health Component (MCS) as dependent variables. Gustilo type, irrigation solution, fracture location, mechanism of injury, degree of contamination, and pre-injury SF-12 scores were included as adjustment variables. All tests were 2-tailed with alpha=0.05. After applying propensity score-matching to adjust for the influence of injury characteristics on type of dressing used, there were 270 matched pairs of patients available for comparison. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.22 times higher in patients who received NPWT compared to those who did not receive NPWT (Odds Ratio (OR) 4.22, 95% Confidence Interval (CI) 2.26–7.87. 1,329 participants were included in our HRQL analysis and those treated with NPWT had significantly lower SF-12 PCS at all follow-up visits (6w, 3m, 6m, 12m) post fracture (p=0.01). Participants treated with NPWT had significantly lower SF-12 MCS at 6-weeks post-fracture (p=0.03). Unlike the X trial, our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management and that being treated with NPWT was associated with lower physical quality of life in the 12 months post-fracture. While there may have been other potential adjustment variables not controlled for in this analysis, our results suggest that the use of this treatment should be re-evaluated

The burden of metastatic bone disease (MBD) in our Canadian cancer population continues to increase. MBD has a significant effect on patient morbidity, mortality, and health-related quality of life (HRQOL). There are various technical options used to surgically stabilize MBD lesions, surgical decision-making is variable and largely dependent on anatomic and surgeon-based factors. There is a paucity of research examining how surgical decision-making for MBD can be modified or individualized to improve quality of life (QOL) and functional outcomes, while more accurately aligning with patient-reported goals and expectations. The objective of this study was tosurvey MBD patients, support persons, physicians, and allied health care providers (HCP) with the goal of identifying 1) important contributors to HRQOL, 2) discordance in peri-operative expectations, and 3) perceived measures of success in the surgical management of MBD. This project is a longitudinal patient-engaged research initiative in MBD. A survey was developed based on HRQOL themes in the literature and based on feedback from our patient research partners. Participants were asked to identify 1) important contributors to HRQOL and 2) perceived measures of success relevant to the surgical management of MBD. Participants were asked to rank themes from ‘extremely important’ to ‘not important at all’. Using open-ended questions, participants were asked to identify areas of improvement. Responses from the open-ended questions were analyzed by an experienced qualitative researcher using conventional content analysis. Participant's demographics were calculated using descriptive statistics. Concordance or discordance of perceived measure of success was assessed via a Chi-Square test of independence. All statistical analyses were performed using IBM SPSS® software. Nine patients, seven support persons, 23 orthopaedic surgeons, 11 medical oncologists, 16 radiation oncologists, 16 nurses, and eight physiotherapists completed the survey. Regarding perceived measures of success, increased life expectancy (p Two main themes emerged around the timeliness of surgical care and the coordination of multidisciplinary care from patients and support persons. Patients and support persons expressed a sense of urgency in progressing to surgery/treatment, and frustration at perceived delays in treatment. Within coordination of care, patients and support persons would like clearer communication from the health care team. There is discordance between patient/support person goals compared to physicians/HCP goals in the surgical management of MBD. Surgical decision-making and operative techniques that minimize disease progression and improve survival are important to MBD patients. Timely access to surgery/surgical consultation and improved multidisciplinary communication is important to patients. This data suggests improved peri-operative communication and education is needed for MBD patients. Furthermore, future research evaluating how modern orthopaedic surgical techniques influence survival and disease progression in MBD is highly relevant and important to patients with MBD

Introduction. Total knee arthroplasty (TKA) is an effective surgical intervention, which alleviates pain and improves function and health-related quality of life in patients with end-stage arthritis of the knee joint. With improvements in anesthesia, general health care, and surgical techniques, this procedure has become widely accepted for use in very elderly patients. However, many elderly patients tend to have compromised function and low reserve capabilities of organs and are therefore likely to develop various complications during the perioperative period. Thus, elderly patients often hesitate to undergo simultaneous bilateral TKA (SBTKA). Our purpose was to report the short-term results and clinical complications of octogenarians undergoing SBTKA. Materials and Methods. Between 2015 and 2016 all patients greater than 80years of age who underwent SBTKA by a single surgeon were retrospectively evaluated demographics, comorbidity, complications, and 30days mortality following SBTKA. Arthroplasty was performed sequentially under general anesthesia by one team led by primary surgeon. After the first knee, the patient's cardiopulmonary status was assessed by anesthesiology to determine whether or not to begin the second side. Cardiopulmonary decompensation, such as significant shifts in heart rate, oxygen saturation or blood pressure, was not showed. Then the second procedure was undertaken. Inclusion criteria of this study was underlying diseases were osteoarthritis. Exclusion criteria were (1) previous knee surgery; (2) underlying diseases were osteonecrosis, rheumatoid arthritis, fracture, and others. Fifty-seven patients with an average age of 82.7years were identified. The results of these procedures were retrospectively compared with those of patients greater than 80years of age of 89 patients unilateral TKA (UTKA) that had been performed by the same surgeon. Results. The study groups did not differ significantly with regard to age, gender, or body mass index. The mean age was 82.7years with a mean body mass index of 25.8 for the SBTKA group, compared with 84.0years with a mean body mass index of 24.9 for the UBTKA group. The length of hospital stay was longer in SBTKA groups. There was no serious complication. No deaths, no pulmonary embolisms and no nerve paralysis occurred within 30days in both groups. There was one wound problem in SBTKA group, compared 10 wound problem in UBTKA group; this difference was significant. Three deliriums occurred in SBTKA group, compared 13 deliriums in UBTKA group; this difference was significant. Minor complications included urinary tract infection, decubitus ulcer, transfusion reaction and ileus were noted seven in SBTKA group, compared in 11 UBTKA group; this difference was not significant. Conclusions. Complications and mortality are not higher for SBTKA compared to UTKA, SBTKA can be a safe and effective option for octogenarians