Introduction. Recurrent patellar dislocation is often reported in bilateral knees in young active individuals. The medial patellofemoral ligament (MPFL) tear is the attributable cause behind many of them and warrants reconstruction of the ligament to stabilize the patellofemoral joint. Besides, trochleoplasty and Fulkerson's osteotomy are some other procedures that are performed to treat this problem. This study aimed to compare the clinical and functional outcomes in a cohort of patients with single-stage bilateral realignment procedures vs staged procedures. Methods. It was a retrospective matched cohort study with prospectively collected data. A total of 36 patients (mean age-26.9 years, range 13 years to 47 years) with recurrent patellar dislocations, who underwent a surgical correction in both the knees, were divided into two matched groups (age, sex, follow-up, and type of procedure). Among them, 18 patients had surgeries in one knee done at least six months later than the other knee. The remaining 18 patients had surgical interventions for both knees done in a single stage. Lysholm, Kujala, Tegner, and subjective knee scores of both groups were compared and analyzed. The rate of complications and return to the theatre were noted in both groups. Results. With a mean follow-up of 7.3 years (2.0 years to 12.3 years), there was a significant improvement in PROMS observed in both the groups (p<0.05). No significant difference could be found between the two groups in terms of the Lysholm, Kujala, and subjective knee scores (p> 0.05). The rate of complication and the re-operation rate was comparable in both the groups (p>0.05). Conclusion. The outcomes of staged vs simultaneous surgeries for bilateral patellofemoral instability are comparable. Our results indicate that simultaneous bilateral surgical correction is safe. This can potentially be an option to reduce the surgical cost and perioperative morbidity. However, careful selection of cases, choice of the patient, and the scope of rehabilitation facilities are some of the other factors that should be considered

Aims. Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI. Methods. A prospective longitudinal study was conducted at a level 1 trauma centre from January 2020 to December 2022. In total, 56 patients treated for FRI were enrolled. The ICD-10 symptom rating (ISR) and an expectation questionnaire were assessed at five timepoints: preoperatively, one month postoperatively, and at three, six, and 12 months. Results. Recurrent FRI cases consistently exceeded the symptom burden threshold (0.60) in ISR scores at all assessment points. The difference between preoperative-assessed total ISR scores and the 12-month follow-up was not significant in either group, with 0.04 for primary FRI (p = 0.807) and 0.01 for recurrent FRI (p = 0.768). While primary FRI patients showed decreased depression scores post surgery, recurrent FRI cases experienced an increase, reaching a peak at 12 months (1.92 vs 0.94; p < 0.001). Anxiety scores rose for both groups after surgery, notably higher in recurrent FRI cases (1.39 vs 1.02; p < 0.001). Moreover, patients with primary FRI reported lower expectations of returning to normal health at three (1.99 vs 1.11; p < 0.001) and 12 months (2.01 vs 1.33; p = 0.006). Conclusion. The findings demonstrate the significant psychological burden experienced by individuals undergoing treatment for FRI, which is more severe in recurrent FRI. Understanding the psychological dimensions of recurrent FRIs is crucial for comprehensive patient care, and underscores the importance of integrating psychological support into the treatment paradigm for such cases. Cite this article: Bone Jt Open 2024;5(7):621–627

Aims. Extensive literature exists relating to the management of shoulder instability, with a more recent focus on glenoid and humeral bone loss. However, the optimal timing for surgery following a dislocation remains unclear. There is concern that recurrent dislocations may worsen subsequent surgical outcomes, with some advocating stabilization after the first dislocation. The aim of this study was to determine if the recurrence of instability following arthroscopic stabilization in patients without significant glenoid bone loss was influenced by the number of dislocations prior to surgery. Methods. A systematic review and meta-analysis was performed using the PubMed, EMBASE, Orthosearch, and Cochrane databases with the following search terms: ((shoulder or glenohumeral) and (dislocation or subluxation) and arthroscopic and (Bankart or stabilisation or stabilization) and (redislocation or re-dislocation or recurrence or instability)). Methodology followed the PRISMA guidelines. Data and outcomes were synthesized by two independent reviewers, and papers were assessed for bias and quality. Results. Overall, 35 studies including 7,995 shoulders were eligible for analysis, with a mean follow-up of 32.7 months (12 to 159.5). The rate of post-stabilization instability was 9.8% in first-time dislocators, 9.1% in recurrent dislocators, and 8.5% in a mixed cohort. A descriptive analysis investigated the influence of recurrent instability or age in the risk of instability post-stabilization, with an association seen with increasing age and a reduced risk of recurrence post-stabilization. Conclusion. Using modern arthroscopic techniques, patients sustaining an anterior shoulder dislocation without glenoid bone loss can expect a low risk of recurrence postoperatively, and no significant difference was found between first-time and recurrent dislocators. Furthermore, high-risk cohorts can expect a low, albeit slightly higher, rate of redislocation. With the findings of this study, patients and clinicians can be more informed as to the likely outcomes of arthroscopic stabilization within this patient subset. Cite this article: Bone Joint J 2024;106-B(10):1141–1149

Abstract. Introduction. Recurrent groin pain following periacetabular osteotomy (PAO) is a challenging problem. The purpose of our study was to evaluate the position and dynamics of the psoas tendon as a potential cause for recurrent groin pain following PAO. Methods. Patients with recurrent groin pain following PAO were identified from a single surgeon series. A total of 13 patients with 18 hips (4.7%) out of a 386 PAO, had recurrent groin pain. Muscle path of the psoas tendon was accurately represented using 3D models from CT data were created with Mimics software. A validated discrete element model using rigid body springs was used to predict psoas tendon movement during hip circumduction and walking. Results. Five out of the 18 hips did not show any malformations at the osteotomy site. Thirteen hips (72%) showed malformation secondary to callus at the superior pubic ramus. These were classified into: osteophytes at the osteotomy site, hypertrophic callus or non-union and malunion at the osteotomy. Mean minimal distance of the psoas tendon to osteophytes was found to be 6.24 mm (n=6) and to the osteotomy site was 14.18 mm (n=18). Conclusions. Recurrent groin pain after PAO needs a thorough assessment. One need to have a high suspicion of psoas issues as a cause. 3D CT scan may be necessary to identify causes related to healing of the pubic osteotomy. Dynamic ultrasound of the psoas psoas tendon may help in evaluating for psoas impingement as a cause of recurrent groin pain in these cases

Aim. We reviewed a cohort of individuals with recurrent orthopaedic infection to describe the relative rates of microbial persistence vs re-infection at recurrence surgery. Method. A cohort of 125 individuals with recurrent infection (prosthetic joint infection, fracture-related infection and osteomyelitis) from two centres in the UK between 2007 and 2021. Electronic patient records were reviewed to identify culture results from surgical samples at index surgery and the next operation for recurrent infection. Antibiotic sensitivity results were recorded as sensitive, intermediate or resistant according to contemporary sensitivity testing guidelines. Results. Among patients with recurrent infection, 78/125 (62.4%) were male, with a median age 64 years (IQR 51–73y). 76 had prosthetic joint infection, and 49 had fracture related infection or osteomyelitis. Culture results at index procedure showed the most frequently isolated species were Staphylococci (Table 1). A single species was isolated in 75/125 (60%) and mixed species in 36/125 (28.8%). No organisms were cultured in 14/125 (11.2%). At re-operation 48/125 (38.4%) individuals had an organism from the same species or group as at the index operation. In 49/125 (39.2%), none of the organisms isolated at re-operation were grown at first operation. In 28/125 (22.4%), re-operative cultures yielded no growth. For each species isolated at the index procedure, the proportion with the same, different or no organisms isolated at the next procedure were reviewed (Table 1). Staphylococci (including S. aureus and coagulase-negative staphylococci) and Pseudomonas species showed the highest rate of persistence at the species level. Among coagulase-negative staphylococci, changes in antimicrobial sensitivity that make it unclear if these infections were truly persistent, or represented re-infection. Conclusions. Infection with different organisms was seen at similar rates (39.2% vs 38.4%) to persistent infection with the same species in this cohort. Staphylococcus aureus is the organism most likely to be persistently identified in recurrent infections

Aims. There is little information in the literature about the use of dual-mobility (DM) bearings in preventing re-dislocation in revision total hip arthroplasty (THA). The aim of this study was to compare the use of DM bearings, standard bearings, and constrained liners in revision THA for recurrent dislocation, and to identify risk factors for re-dislocation. Methods. We reviewed 86 consecutive revision THAs performed for dislocation between August 2012 and July 2019. A total of 38 revisions (44.2%) involved a DM bearing, while 39 (45.3%) and nine (10.5%) involved a standard bearing and a constrained liner, respectively. Rates of re-dislocation, re-revision for dislocation, and overall re-revision were compared. Radiographs were assessed for the positioning of the acetabular component, the restoration of the centre of rotation, leg length, and offset. Risk factors for re-dislocation were determined by Cox regression analysis. The modified Harris Hip Scores (mHHSs) were recorded. The mean age of the patients at the time of revision was 70 years (43 to 88); 54 were female (62.8%). The mean follow-up was 5.0 years (2.0 to 8.75). Results. DM bearings were used significantly more frequently in elderly patients (p = 0.003) and in hips with abductor deficiency (p < 0.001). The re-dislocation rate was 13.2% for DM bearings compared with 17.9% for standard bearings, and 22.2% for constrained liners (p = 0.432). Re-revision-free survival for DM bearings was 84% (95% confidence interval (CI) 0.77 to 0.91) compared with 74% (95% CI 0.67 to 0.81) for standard articulations, and 67% (95% CI 0.51 to 0.82) for constrained liners (p = 0.361). Younger age (hazard ratio (HR) 0.92 (95% CI 0.85 to 0.99); p = 0.031), lower comorbidity (HR 0.44 (95% CI 0.20 to 0.95); p = 0.037), smaller heads (HR 0.80 (95% CI 0.64 to 0.99); p = 0.046), and retention of the acetabular component (HR 8.26 (95% CI 1.37 to 49.96); p = 0.022) were significantly associated with re-dislocation. All DM bearings which re-dislocated were in patients with abductor muscle deficiency (HR 48.34 (95% CI 0.03 to 7,737.98); p = 0.303). The radiological analysis did not reveal a significant relationship between restoration of the geometry of the hip and re-dislocation. The mean mHHSs significantly improved from 43 points (0 to 88) to 67 points (20 to 91; p < 0.001) at the final follow-up, with no differences between the types of bearing. Conclusion. We found that the use of DM bearings reduced the rates of re-dislocation and re-revision in revision THA for recurrent dislocation, but did not guarantee stability. Abductor deficiency is an important predictor of persistent instability. Cite this article: Bone Joint J 2024;106-B(5 Supple B):89–97

Osteochondromas are benign chondrogenic lesions arising on the external surface of the bone with aberrant cartilage (exostosis) from the perichondral ring that may contain a marrow cavity also. In a few cases, depending on the anatomical site affected, different degrees of edema, redness, paresthesia, or paresis can take place due to simple contact or friction. Also, depending on their closeness to neurovascular structures, the procedure of excision becomes crucial to avoid recurrence. We report a unique case of recurrent osteochondroma of the proximal humerus enclosing the brachial artery which makes for an important case and procedure to ensure that no relapse occurs. We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. The swelling size was 4.4 cm x 3.7 cm x 4 cm with a previous history of swelling at the same site operated in 2018. CT reports were suggestive of a large well defined broad-based exophytic diaphyseal lesion in the medial side of the proximal humerus extending posteriorly. Another similar morphological lesion measuring approximately 9 mm x 7 mm was noted involving the posterior humeral shaft. The minimal distance between the lesion and the brachial artery was 2 mm just anterior to the posterio-medial growth. Two intervals were made, first between the tumor and the neurovascular bundle and the other between the anterior tumor and brachial artery followed by exostosis and cauterization of the base. Proper curettage and excision of the tumor was done after dissecting and removing the soft tissue, blood vessels, and nerves so that there were very less chances of relapse. Post-operative X-ray was done and post 6 months of follow-up, there were no changes, and no relapse was observed. Thus, when presented with a case of recurrent osteochondroma of the proximal humerus, osteochondroma could also be in proximity to important vasculature as in this case enclosing the brachial artery. Thus, proper curettage and excision should be done in such cases to avoid recurrence

Aims. The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR). Methods. This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport. Results. At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level. Conclusion. Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718–724

Recurrent patellar instability is a common problem and there are multiple demographic and pathoanatomic risk factors that predispose patients to dislocating their patella. The most common of these is trochlear dysplasia. In cases of severe trochlear dysplasia associated with patellar instability, a sulcus deepening trochleoplasty combined with a medial patellofemoral ligament reconstruction (MPFLR) may be indicated. Unaddressed trochlear pathology has been associated with failure and poor post-operative outcomes after stabilization. The purpose of this study is to report the clinical outcome of patients having undergone a trochleoplasty and MPFLR for recurrent lateral patellofemoral instability in the setting of high-grade trochlear dysplasia at a mean of 2 years follow-up. A prospectively collected database was used to identify 46 patients (14 bilateral) who underwent a combined primary MPFLR and trochleoplasty for recurrent patellar instability with high-grade trochlear dysplasia between August 2013 and July 2021. A single surgeon performed a thin flap trochleoplasty using a lateral para-patellar approach with lateral retinaculum lengthening in all 60 cases. A tibial tubercle osteotomy (TTO) was performed concomitantly in seven knees (11.7%) and the MPFLR was performed with a gracilis tendon autograft in 22%, an allograft tendon in 27% and a quadriceps tendon autograft in 57% of cases. Patients were assessed post-operatively at three weeks and three, six, 12 and 24 months. The primary outcome was the Banff Patellar Instability Instrument 2.0 (BPII 2.0) and secondary outcomes were incidence of recurrent instability, complications and reoperations. The mean age was 22.2 years (range, 13 to 45), 76.7% of patients were female, the mean BMI was 25.03 and the prevalence of a positive Beighton score (>4/9) was 40%. The mean follow-up was 24.3 (range, 6 to 67.7) months and only one patient was lost to follow-up before one year post-operatively. The BPII 2.0 improved significantly from a mean of 27.3 pre-operatively to 61.1 at six months (p < 0 .01) and further slight improvement to a mean of 62.1 at 12 months and 65.6 at 24 months post-operatively. Only one patient (1.6%) experienced a single event of subluxation without frank dislocation at nine months. There were three reoperations (5%): one for removal of the TTO screws and prominent chondral nail, one for second-look arthroscopy for persistent J-sign and one for mechanical symptoms associated with overgrowth of a lateral condyle cartilage repair with a bioscaffold. There were no other complications. In this patient cohort, combined MPFLR and trochleoplasty for recurrent patellar instability with severe trochlear dysplasia led to significant improvement of patient reported outcome scores and no recurrence of patellar dislocation at a mean of 2 years. Furthermore, in this series the procedure demonstrated a low rate (5%) of complications and reoperations

Abstract. Objectives. Intra-articular corticosteroid injections (IACIs) are a well-established non-surgical treatment for the symptoms of osteoarthritis (OA), which can provide short-term improvements in pain, disability and quality of life (QoL). Many patients receive recurrent IACIs as temporary relief of their symptoms. Longer-term outcomes for recurrent IACIs remain less well-researched. This meta-analysis aimed to investigate the longer-term risks and benefits of IACIs beyond 3 months. Methods. We searched MEDLINE, EMBASE, and CENTRAL from inception to January 07, 2021, for randomised controlled trials (RCTs) where patients with OA had received recurrent IACIs. Our primary outcomes were pain and function. Secondary outcomes included QoL, disease progression, radiological changes, and adverse events. Mean differences with 95% confidence intervals were reported. Results. Ten RCTs met eligibility criteria (eight for knee OA [n=378], two for trapeziometacarpal OA [n=57]). Patients received 2–5 injections. Follow-up ranged from 6–24 months. Patients with knee OA showed mild improvement in pain at 3, 6, and 9 months but not at 12 months post-injection compared to baseline. Improvements in function were seen from 3–24 months post-injection, decreasing over time. Improvements in QoL continued at 24 months. For patients with trapeziometacarpal OA, mild improvements in pain, function, and QoL were demonstrated at 3–6 months (and 12 months for pain) compared to baseline. No serious adverse events were recorded. No studies reported on time-to-future interventions, or risk of future periprosthetic joint infection. Conclusions. Only mild improvements in pain, function, and QoL were noted after recurrent IACIs up to 6–24 months post-injection. Existing RCTs on recurrent IACI lacks sufficient follow-up data to assess disease progression and time-to-future interventions. These results will inform the RecUrrent Intra-articular Corticosteroid injections in Osteoarthritis (RUbICOn) study which aims to establish the long-term safety outcomes of IACI through data linkage of clinical practice data, hospital episode statistics, and national PROMs

Aims. To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. Methods. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Results. Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. Conclusion. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management. Cite this article: Bone Joint J 2023;105-B(3):315–322

Dual-mobility (DM) bearings are effective to mitigate dislocation in revision total hip arthroplasty (THA). However, data on its use for treating dislocation is scarce. Aim of this study was to compare DM bearings, standard bearings and constrained liner (CL) in revision THA for recurrent dislocation and to identify risk factors for re-dislocation. We reviewed 100 consecutive revision THAs performed for dislocation from 2012 and 2019. 45 hips (45%) received a DM construct, while 44 hips (44%) and 11 hips (11%) had a standard bearing and CL, respectively. Rates of re-dislocation, re-revision for dislocation and overall re-revision were compared. Radiographs were assessed for cup positioning, restoration of centre of rotation, leg length and offset. Risk factors for re-dislocation were determined by cox regression analysis. Modified Harris hip scores (mHHS) were calculated. Mean follow-up was 53 months (1 to 103). DM constructs were used more frequently in elderly patients (p=0.011) and hips with abductor deficiency (p< 0.001). The re-dislocation rate was 11.1% for DM bearings compared with 15.9% for standard bearings and 18.2% for CL (p=0.732). Revision-free survival for DM constructs was 83% (95% CI 0.77 – 0.90) compared to 75% (95% CI 0.68 – 0.82) for standard articulations and 71% (95% CI 0.56 – 0.85) for CL (p=0.455). Younger age (HR 0.91; p=0.020), lower comorbidity (HR 0.42; p=0.031), smaller heads (HR 0.80; p=0.041) and cup retention (HR 8.23; p=0.022) were associated with re-dislocation. Radiological analysis did not reveal a relationship between restoration of hip geometry and re-dislocation. mHHS significantly improved from 43.8 points to 65.7 points (p<0.001) with no differences among bearing types. Our findings suggest that DM bearings do not sufficiently prevent dislocation in revision THA for recurrent dislocation. Reconstruction of the abductor complex may play a key role to reduce the burden in these high-risk patients

Aims. The purpose of this study was to determine whether intracellular Staphylococcus aureus is associated with recurrent infection in a rat model of open fracture. Methods. After stabilizing with Kirschner wire, we created a midshaft femur fracture in Sprague-Dawley rats and infected the wound with green fluorescent protein (GFP)-tagged S. aureus. After repeated debridement and negative swab culture was achieved, the isolation of GFP-containing cells from skin, bone marrow, and muscle was then performed. The composition and viability of intracellular S. aureus in isolated GFP-positive cells was assessed. We suppressed the host immune system and observed whether recurrent infection would occur. Finally, rats were assigned to one of six treatment groups (a combination of antibiotic treatment and implant removal/retention). The proportion of successful eradication was determined. Results. Green fluorescent protein-containing cells were successfully isolated after the swab culture was negative from skin (n = 0, 0%), muscle (n = 10, 100%), and bone marrow (n = 10, 100%) of a total of ten rats. The phagocytes were predominant in GFP-positive cells from muscle (73%) and bone marrow (81%) with a significantly higher viability of intracellular S. aureus (all p-values < 0.001). The recurrent infection occurred in up to 75% of rats after the immunosuppression. The proportion of successful eradication was not associated with implant retention or removal, and the efficacy of linezolid in eradicating intracellular S. aureus is significantly higher than that of vancomycin. Conclusion. Intracellular S. aureus is associated with recurrent infection in the rat model of open fracture. Usage of linezolid, a membrane-permeable antibiotic, is an effective strategy against intracellular S. aureus. Cite this article:Bone Joint Res. 2020;9(2):71–76

Aims. The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient’s experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years. Methods. A total of 350 patients with anterior instability of the shoulder who underwent an open Latarjet procedure between 2005 and 2018 were reviewed prospectively, with the collection of demographic and psychosocial data, preoperative CT, and complications during follow-up of two years. The primary outcome measure was the Western Ontario Shoulder Instability Index (WOSI), assessed preoperatively, at two years postoperatively, and at mid-term follow-up at a mean of 50.6 months (SD 24.8) postoperatively. The secondary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. The influence of the demographic details of the patients, measurements of the severity of instability, and the complications of surgery were assessed in a multivariate analysis. Results. The mean age of the patients was 25.5 years (22 to 32) and 27 (7.7%) were female. The median time to surgery after injury was 19 months (interquartile range (IQR) 13 to 39). Seven patients developed clinically significant complications requiring further intervention within two years of surgery. The median percentage WOSI deficiency was 8.0% (IQR 4 to 20) and median QuickDASH was 3.0 (IQR 0 to 9) at mid-term assessment. A minority of patients reported a poorer experience, and 22 (6.3%) had a > 50% deficiency in WOSI score. Multivariate analysis revealed that consumption of ≥ 20 units of alcohol/week, a pre-existing affective disorder or epilepsy, medicolegal litigation, increasing time to surgery, and residing in a more socioeconomically deprived area were independently predictive of a poorer WOSI score. Conclusion. Although most patients treated by an open Latarjet procedure have excellent outcomes at mid-term follow-up, a minority have poorer outcomes, which are mainly predictable from pre-existing demographic factors, rather than measures of the severity of instability. Cite this article: Bone Joint J 2023;105-B(4):389–399

Aims. While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA. Patients and Methods. Prospectively collected data on 111 patients undergoing revision THA for recurrent instability from January 2014 to January 2017 at two institutions were included (protocol group) and matched 1:1 to 111 revisions specifically performed for instability not using this protocol (control group). Mean follow-up was 2.8 years. Protocol patients underwent standardized preoperative imaging including supine and standing anteroposterior (AP) pelvis and lateral radiographs. Each case was scored according to the Hip-Spine Classification in Revision THA. Results. Survival free of dislocation at two years was 97% in the protocol group (three dislocations, all within three months of surgery) versus 84% in the control group (18 patients). Furthermore, 77% of the inappropriately positioned acetabular components would have been unrecognized by supine AP pelvis imaging alone. Conclusion. Using the Hip-Spine Classification System in revision THA, we demonstrated a significant decrease in the risk of recurrent instability compared with a control group. Without the use of this algorithm, 77% of inappropriately positioned acetabular components would have been unrecognized and incorrect treatment may have been instituted. Cite this article: Bone Joint J 2019;101-B:817–823

Aims. We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable. Methods. Consecutive patients who had an operation for recurrent posterior instability before the age of 18 years were studied retrospectively. All patients had failed conservative treatment for at least six months prior to surgery; and no patients had psychiatric disorders. Two groups were identified and compared: voluntary posterior instability starting in childhood which became uncontrollable and involuntary (group VBI); and involuntary posterior instability (group I). Patients were reviewed and assessed at least two years after surgery by two examiners. Results. In all 38 patients (40 shoulders) were included: group I (20 shoulders), with involuntary posterior instability (onset at 14 years of age (SD 2.3), and group VBI (20 shoulders), with initially voluntary posterior instability (onset at 9 years of age (SD 2.6) later becoming involuntary (16 years of age (SD 3.5). Mean age at surgery was 20 years (SD 4.6 years; 12 to 35). A posterior bone block was performed in 18 patients and a posterior capsular shift in 22. The mean follow-up was 7.7 years (2 to 18). Recurrence of posterior instability was seen in nine patients, 30% in group VBI (6/20 shoulders) and 15% in group I (3/20 shoulders) (p > 0.050). At final follow-up, the shoulder's of two patients in each group had been revised. No differences between either group were found for functional outcomes, return to sport, subjective, and radiological results. Conclusion. Although achieving stability in patients with so-called voluntary instability, which evolves into an involuntary condition, is difficult, shoulder stabilization may be undertaken with similar outcomes to those patients treated surgically for involuntary instability. Cite this article: Bone Joint J 2020;102-B(12):1760–1766

The Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0) is a patient-reported disease-specific quality of life (QOL) outcome measure used to assess patients with recurrent lateral patellofemoral instability (LPI) both pre- and post-operatively. The purpose of this study was to compare the BPII 2.0 to four other relevant patient reported outcome measures (PROMs): the Tampa Scale-11 for kinesiophobia (TSK-11), the pain catastrophizing scale (PCS), a general QOL (EQ-5D-5L), and a return to sport index (ACL-RSI). This concurrent validation sought to compare and correlate the BPII 2.0 with these other measures of physical, psychological, and emotional health. The psychological and emotional status of patients can impact recovery and rehabilitation, and therefore a disease-specific PROM may be unable to consistently identify patients who would benefit from interventions encompassing a holistic and person-focused approach in addition to disease-specific treatment. One hundred and ten patients with recurrent lateral patellofemoral instability (LPI) were assessed at a tertiary orthopaedic practice between January and October 2021. Patients were consented into the study and asked to complete five questionnaires: the BPII 2.0, TSK-11, PCS, EQ-5D-5L, and the ACL-RSI at their initial orthopaedic consultation. Descriptive demographic statistics were collected for all patients. A Pearson's r correlation coefficient was employed to examine the relationships between the five PROMs. These analyses were computed using SPSS 28.0 © (IBM Corporation, 2021). One hundred and ten patients with a mean age of 25.7 (SD = 9.8) completed the five PROMs. There were 29 males (26.3%) and 81 females (73.6%) involving 50% symptomatic left knees and 50% symptomatic right knees. The mean age of the first dislocation was 15.4 years (SD = 7.3; 1-6) and the mean BMI was 26.5 (SD = 7.3; range = 12.5-52.6) The results of the Pearson's r correlation coefficient demonstrated that the BPII 2.0 was statistically significantly related to all of the assessed PROM's (p. There was significant correlation evident between the BPII 2.0 and the four other PROMs assessed in this study. The BPII 2.0 does not explicitly measure kinesiophobia or pain catastrophizing, however, the significant statistical relationship of the TSK-11 and PCS to the BPII 2.0 suggests that this information is being captured and reflected. The preliminary results of this concurrent validation suggest that the pre-operative data may offer predictive validity. Future research will explore the ability of the BPII 2.0 to predict patient quality of life following surgery

Total Knee Arthroplasty (TKA) necessitates disruption of well-vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal postoperative setting, and when mild, may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome, with increased wound infection rates when prolonged drainage is allowed to persist. While excessive bleeding during the early postoperative period is most common, isolated or recurrent hemarthrosis may occur long after recovery from surgery. The incidence of postoperative hemarthrosis is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after TKA and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial workup should include coagulation studies to rule out any underlying systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time but is not commonly diagnosed until the patient has left the early recovery period. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, classical treatment has consisted of open or arthroscopic synovectomy. Over the past decade angiography and angiographic embolization of the source of bleeding has been successful. In a recent meta-analysis including 99 patients, technical success rates of 99% were noted, though 2 cases became infected and 10 cases suffered recurrent bleeding episodes. Radio-active synovectomy has also been successful

Aims. The factors that predispose to recurrent instability and revision stabilization procedures after arthroscopic Bankart repair for anterior glenohumeral instability remain unclear. We sought to determine the rate and risk factors associated with ongoing instability in patients undergoing arthroscopic Bankart repair for instability of the shoulder. Materials and Methods. We used the Statewide Planning and Research Cooperative System (SPARCS) database to identify patients with a diagnosis of anterior instability of the shoulder undergoing arthroscopic Bankart repair between 2003 and 2011. Patients were followed for a minimum of three years. Baseline demographics and subsequent further surgery to the ipsilateral shoulder were analyzed. Multivariate analysis was used to identify independent risk factors for recurrent instability. Results. A total of 5719 patients were analyzed. Their mean age was 24.9 years (. sd.  9.3); 4013 (70.2%) were male. A total of 461 (8.1%) underwent a further procedure involving the ipsilateral shoulder at a mean of 31.5 months (. sd.  23.8) postoperatively; 117 (2.1%) had a closed reduction and 344 (6.0%) had further surgery. Revision arthroscopic Bankart repair was the most common subsequent surgical procedure (223; 65.4%). Independent risk factors for recurrent instability were: age < 19 years (odds ratio 1.86), Caucasian ethnicity (hazard ratio 1.42), bilateral instability of the shoulder (hazard ratio 2.17), and a history of closed reduction(s) prior to the initial repair (hazard ratio 2.45). Revision arthroscopic Bankart repair was associated with significantly higher rates of ongoing persistent instability than revision open stabilization (12.4% vs 5.1%, p = 0.041). Conclusion. The incidence of a further procedure being required in patients undergoing arthroscopic Bankart repair for anterior glenohumeral instability was 8.1%. Younger age, Caucasian race, bilateral instability, and closed reduction prior to the initial repair were independent risk factors for recurrent instability, while subsequent revision arthroscopic Bankart repair had significantly higher rates of persistent instability than subsequent open revision procedures. Cite this article: Bone Joint J 2018;100-B:324–30

Although the incidence of total hip dislocation has decreased, it still remains a major problem particularly if recurrent. The actual incidence is around 1–2% but it has been documented as the leading cause for hip revision in the United States. In patients with recurrent hip dislocation, technical issues of leg length inequality, incorrect offset, and poor implant position should be addressed surgically and the abnormality corrected. In patients with recurrent hip dislocation, the articulation is preferably converted to a more stable articulation, with constrained sockets and dual mobility being the choices. In my experience, dual mobility articulations remain an excellent option for recurrent hip dislocation and its use is increasing significantly. It provides improved hip stability and data have demonstrated good success with recurrent hip dislocation. However, with use of the modular variety of dual mobility which is needed for acetabular cup fixation with screw augmentation, dissimilar metals are placed in contact (titanium socket and cobalt chrome liner insert) which potentially can pose a fretting or corrosion problem in longer term outcomes. Constrained sockets of the tripolar configuration provide another option which is useful in those patients with severe abductor dysfunction or insufficiency. Constrained sockets can also be cemented into the existing shell in cases where there is a well-fixed cup and cup removal may lead to significant bone loss and a need for complex acetabular reconstruction. It is important to remember that there are two types of constrained sockets, tripolar and focal constraint. Results with the tripolar constrained socket have been significantly better than the focal constraint variety which adds a polyethylene rim piece to the liner. In a mid-term follow up (2–9 years) of 116 constrained tripolar sockets, recurrent dislocation was only 3.3%. In papers reporting on focal constrained sockets, recurrent dislocation was in the 9–29% range. There continues to be a role for constrained sockets and selection of implant type has made a difference in ultimate outcome