This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed. Cite this article: Bone Joint J 2022;104-B(12):1329–1333

Aims. The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment. Methods. Patients who underwent surgery for complex radial head fractures (Mason type III, ≥ three fragments) were divided into two groups (ORIF and RHA) and propensity score matching was used to individually match patients based on patient characteristics. Ultimately, 84 patients were included in this study. After a mean follow-up of 4.1 years (2.0 to 9.5), patients were invited for clinical and radiological assessment. The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score were evaluated. Results. Patients treated with ORIF showed significantly better postoperative range of motion for flexion and extension (121.1° (SD 16.4°) vs 108.1° (SD 25.8°); p = 0.018). Postoperative functional scores also showed significantly better results in the ORIF group (MEPS 90.1 (SD 13.6) vs 78 (SD 20.5); p = 0.004). There was no significant difference between the groups in terms of the complication rate (RHA 23.8% (n = 10) vs ORIF 26.2% (n = 11)). Implant-related complications occurred in six cases (14.3%) in the RHA group and in five cases (11.9%) in the ORIF group. Conclusion. Irrespective of the patient’s age, sex, type of injury, or number of fracture fragments, ORIF of the radial head should be attempted initially, if a stable reconstruction can be achieved, as it seems to provide a superior postoperative outcome for the patient compared to primary RHA. If reconstruction is not feasible, RHA is still a viable alternative. In the surgical treatment of complex radial head fractures, reconstruction shows superior postoperative outcomes compared to RHA. Good postoperative results can be achieved even after failed reconstruction and conversion to secondary RHA. Therefore, we encourage surgeons to favour reconstruction of complex radial head fractures, regardless of injury type or number of fragments, as long as a stable fixation can be achieved. Cite this article: Bone Joint J 2024;106-B(10):1158–1164

Distal radius fractures (DRFs) are common injuries that represent 17% of all adult upper extremity fractures. Some fractures deemed appropriate for nonsurgical management following closed reduction and casting exhibit delayed secondary displacement (greater than two weeks from injury) and require late surgical intervention. This can lead to delayed rehabilitation and functional outcomes. This study aimed to determine which demographic and radiographic features can be used to predict delayed fracture displacement. This is a multicentre retrospective case-control study using radiographs extracted from our Analytics Data Integration, Measurement and Reporting (DIMR) database, using diagnostic and therapeutic codes. Skeletally mature patients aged 18 years of age or older with an isolated DRF treated with surgical intervention between two and four weeks from initial injury, with two or more follow-up visits prior to surgical intervention, were included. Exclusion criteria were patients with multiple injuries, surgical treatment with fewer than two clinical assessments prior to surgical treatment, or surgical treatment within two weeks of injury. The proportion of patients with delayed fracture displacement requiring surgical treatment will be reported as a percentage of all identified DRFs within the study period. A multivariable conditional logistic regression analysis was used to assess case-control comparisons, in order to determine the parameters that are mostly likely to predict delayed fracture displacement leading to surgical management. Intra- and inter-rater reliability for each radiographic parameter will also be calculated. A total of 84 age- and sex-matched pairs were identified (n=168) over a 5-year period, with 87% being female and a mean age of 48.9 (SD=14.5) years. Variables assessed in the model included pre-reduction and post-reduction radial height, radial inclination, radial tilt, volar cortical displacement, injury classification, intra-articular step or gap, ulnar variance, radiocarpal alignment, and cast index, as well as the difference between pre- and post-reduction parameters. Decreased pre-reduction radial inclination (Odds Ratio [OR] = 0.54; Confidence Interval [CI] = 0.43 – 0.64) and increased pre-reduction volar cortical displacement (OR = 1.31; CI = 1.10 – 1.60) were significant predictors of delayed fracture displacement beyond a minimum of 2-week follow-up. Similarly, an increased difference between pre-reduction and immediate post reduction radial height (OR = 1.67; CI = 1.31 – 2.18) and ulnar variance (OR = 1.48; CI = 1.24 – 1.81) were also significant predictors of delayed fracture displacement. Cast immobilization is not without risks and delayed surgical treatment can result in a prolong recovery. Therefore, if reliable and reproducible radiographic parameters can be identified that predict delayed fracture displacement, this information will aid in earlier identification of patients with DRFs at risk of late displacement. This could lead to earlier, appropriate surgical management, rehabilitation, and return to work and function

Periprosthetic femoral fractures are increasing in incidence, and typically occur in frail elderly patients. They are similar to pathological fractures in many ways. The aims of treatment are the same, including 'getting it right first time' with a single operation, which allows immediate unrestricted weightbearing, with a low risk of complications, and one that avoids the creation of stress risers locally that may predispose to further peri-implant fracture. The surgical approach to these fractures, the associated soft-tissue handling, and exposure of the fracture are key elements in minimizing the high rate of complications. This annotation describes the approaches to the femur that can be used to facilitate the surgical management of peri- and interprosthetic fractures of the femur at all levels using either modern methods of fixation or revision arthroplasty. Cite this article: Bone Joint J 2023;105-B(6):593–601

Aims. Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied. Methods. In an observational cohort study on 8,031 FNF patients with THA between January 2005 and December 2014, Swedish Arthroplasty Register data were linked with the National Patient Register, recording the total dislocation rates at one year and revision rates at three years after surgery. The cumulative incidence of events was estimated using the Kaplan-Meier method. Cox multivariable regression models were fitted to calculate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for the risk of dislocation, revision, or mortality, stratified by surgical approach. Results. The cumulative dislocation rate at one year was 8.3% (95% CI 7.3 to 9.3) for patients operated on using the posterior approach and 2.7% (95% CI 2.2 to 3.2) when using the direct lateral approach. In the posterior approach group, use of DMC was associated with reduced adjusted risk of dislocation compared to 32 mm heads (HR 0.21 (95% CI 0.07 to 0.68); p = 0.009). This risk was increased with head sizes < 32 mm (HR 1.47 (95% CI 1.10 to 1.98); p = 0.010). Neither DMC nor different head sizes influenced the risk of revision following the posterior approach. Neither articulation was associated with a statistically significantly reduced adjusted risk of dislocation in patients where the direct lateral approach was performed, although this risk was estimated to be HR 0.14 (95% CI 0.02 to 1.02; p = 0.053) after the use of DMC. DMC inserted through a direct lateral approach was associated with a reduced risk of revision for any reason versus THA with 32 mm heads (HR 0.36 (95% CI 0.13 to 0.99); p = 0.047). Conclusion. When using a posterior approach for THA in FNF patients, DMC reduces the risk of dislocation, while a non-significant risk reduction is seen for DMC after use of the direct lateral approach. The direct lateral approach is protective against dislocation and is also associated with a lower rate of revision at three years, compared to the posterior approach. Cite this article: Bone Joint J 2022;104-B(7):844–851

Aims. The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome. Methods. Prospectively collected data of a consecutive single-surgeon cohort, operated for FAI between January 2005 and January 2015, were retrospectively studied. The cohort comprised 393 hips (365 patients; 71% male (n = 278)), with a mean age of 34.5 years (SD 10.0). Over the study period, techniques evolved from open surgical dislocation (n = 94) to a combined arthroscopy-Hueter technique (HA + Hueter; n = 61) to a pure arthroscopic technique (HA; n = 238). Outcome measures of interest included modes of failures, complications, reoperation, and patient-reported outcome measures (PROMs). Demographic, radiological, and surgical factors were tested for possible association with outcome. Results. At a mean follow-up of 7.5 years (SD 2.5), there were 43 failures in 38 hips (9.7%), with 35 hips (8.9%) having one failure mode, one hip (0.25%) having two failure modes, and two hips (0.5%) having three failure modes. The five- and ten-year hip joint preservation rates were 94.1% (SD 1.2%; 95% confidence interval (CI) 91.8 to 96.4) and 90.4% (SD 1.7%; 95% CI 87.1 to 93.7), respectively. Inferior survivorship was detected in the surgical dislocation group. Age at surgery, Tönnis grade, cartilage damage, and absence of rim-trimming were associated with improved preservation rates. Only Tönnis grade was an independent predictor of hip preservation. All PROMs improved postoperatively. Factors associated with improvement in PROMs included higher lateral centre-edge and α angles, and lower retroversion index and BMI. Conclusion. FAI surgery provides lasting improvement in function and a joint preservation rate of 90.4% at ten years. The evolution of practice was not associated with inferior outcome. Since degree of arthritis is the primary predictor of outcome, improved awareness and screening may lead to prompt intervention and better outcomes. Cite this article: Bone Jt Open 2022;3(10):804–814

Introduction. Deformations of forearm with different degree of expression and functional restrictions of upper limb in children with hereditary multiple exostosis are formed in almost 80% of the cases. The question of indications for the selection and conduct of surgical procedure remains controversial, existing treatment methods and post-operative recovery methods for children need to be improved. Materials and Methods. The long-term outcomes of surgical treatment of 112 patients diagnosed with “Hereditary Multiple Exostosis” (HME) aged from 2 till 17 years old were researched. Evaluation of surgical treatment results was carried out in accordance with complaints, functional condition of the forearm, radiographs (taking into account reference lines and angles). Depending on the variant of deformation, the following surgical operations were performed: resection of bone-cartilage exostoses (in 20.5%); correction of forearm deformation with external fixator (in 79.5). In 14 cases, for a more accurate correction of deformity a hexapod frame was used. Results. Differentiated approach provided “good” anatomical and functional results in 55.6%; “satisfactory” results in 40.2%; “unsatisfactory” results in 4.2%. Postoperative complications in the form of non-union, pseudoarthrosis, delayed consolidation or neurological disorders were in 6.2%. Conclusions. The choice of surgical treatment is determined by the variant and severity of deformation. This approach allows to improve cosmetic and functional condition of forearm and adjacent joints. The use of hexapod allows to increase accuracy of correction of physiological axis of forearm bones

Aims. A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications. Patients and Methods. The electronic medical records of all patients who underwent primary elective THA at a single large-volume arthroplasty centre, between 2011 and 2016, with at least two years of follow-up, were reviewed. After exclusion, 3574 consecutive patients were included in the study. There were 1571 men (44.0%) and 2003 women (56.0%). Their mean age and body mass index (BMI) was 63.0 years (. sd. 11.8) and 29.1 kg/m. 2. (. sd. 6.1), respectively. Data gathered included the age of the patient, BMI, the American Society of Anesthesiologists (ASA) score, estimated blood loss (EBL), length of stay (LOS), operating time, the presence of intra- or postoperative complications, type of complication, and the surgical approach. The approaches used during the study were posterior, anterior, direct lateral, anterolateral, and the northern approach. The complications that were recorded included prolonged wound drainage without infection, superficial infection, deep infection, dislocation, aseptic loosening, and periprosthetic fracture. Finally, the need for re-operation was recorded. Means were compared using analysis of variance (ANOVA) and Student’s t-tests where appropriate and proportions were compared using the chi-squared test. Results. A total of 248 patients had 263 complications related to the surgery, with an incidence of 6.94%. The anterior approach had the highest incidence of complications (8.5% (113/1329)) and the posterior approach had the lowest, at 5.85% (97/1657; p = 0.006). Most complications were due to deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%). The rate of dislocation was 0.84% (14/1657) with the posterior approach and 1.28% (17/1329) with the anterior approach (p = 0.32). Conclusion. Overall, THA has a relatively low complication rate. However, the surgical approach plays a role in the incidence of complications. We found that the posterior approach had a significantly lower overall complication rate compared with the anterior approach, with an equal dislocation rate. Periprosthetic fracture and surgical site infection contributed most to the early complication rates. Cite this article: Bone Joint J 2019;101-B:646–651

Aim. A septic revision of an artificial joint is routinely split up in a so-called dirty phase and a clean phase. The measures taken to initiate the start of the clean phase vary significantly between musculoskeletal infection centers. We performed simulations of one-step exchanges of infected THAs and sought to 1) determine the effect of different clean phase protocols on the sterile field, and 2) determine whether or not it is possible to re-implant the new prosthesis completely clean. Method. Nine fresh frozen cadaveric hips were used and primary THA was undertaken via a direct anterior approach. Before implantation of the components varying amounts of fluorescent powder (GloGerm) were deposited, simulating bacterial infection. Second, a one-step exchange was performed via a posterolateral approach. After implant removal, debridement, and lavage, randomization determined which clean phase protocol was followed, i.e. no, some or full additional measures. Finally, the new prosthesis was re-implanted (fig. 1). In order to determine the effect of different clean phase protocols on contamination of the sterile field standardized UV light-enhanced photographs were obtained of 1) the gloves, 2) the instrument table, 3) the drapes, and 4) the wound and these were ranked on cleanliness by a blind panel of hip surgeons. In order to determine whether or not it is possible to re-implant the prosthesis completely clean, the implant was taken out again at the end of the one-step exchange and inspected for contamination under UV light. Results. The gloves, the instrument table, the drapes (fig. 2) and the wound were significantly cleaner after a clean phase using full additional measures compared to partial or no additional measures (p < 0.000). Partial measures were able to reduce some of the contamination of the gloves and the wound, but had no effect on the drapes and the instrument table. All re-implanted implants were contaminated with some amount of fluorescent powder at the end of the one-step exchange. Conclusions. We advise to incorporate a clean phase with full additional measures into the surgical treatment of prosthetic joint infections, as the effect of partial measures seems to be a poor compromise. The results of this study have now been published: Vles G, Bossen J, Kloos J, Debeer P, Ghijselings S. On the value and limitations of incorporating a “clean phase” into the surgical treatment of prosthetic joint infections - an illustrative cadaveric study using fluorescent powder. J Exp Orthop. 2022 Mar 21;9(1):28. doi: 10.1186/s40634-022-00467-x

Aims. To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes. Methods. Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible. Results. At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures. Conclusion. Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620–1628

Aims. Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets. Methods. This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling. Results. A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17). Conclusion. We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets. Cite this article: Bone Joint J 2024;106-B(9):994–999

Aims. The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results. Patients and Methods. A total of 78 patients with a Monteggia-like lesion, including 44 women and 34 men with a mean age of 54.7 years (19 to 80), were available for assessment after a mean 4.6 years (2 to 9.2). The outcome was assessed using the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Mayo Modified Wrist Score (MMWS), and The Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiographs were analyzed for all patients. A total of 12 Mason type I, 16 type II, and 36 type III fractures were included. Surgical treatment consisted of screw fixation for all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) or excision was performed if reconstruction was not possible. Results. The mean MEPS was 88.9 (40 to 100), mean OES was 40.1 (25 to 48), mean MMWS was 88.1 (50 to 100), mean DASH score was 14.7 (0 to 60.2), and mean movement was 114° (. sd. 27) in extension/flexion and 155° (. sd. 37) in pronation/supination. Mason III fractures, particularly those with an associated coronoid fracture treated with RHA, had a significantly poorer outcome. Suboptimal results were also identified in patients who had degenerative changes or heterotopic ossification on their latest radiograph. In contrast, all patients with successful radial head reconstruction or excision had a good outcome. Conclusion. Good outcomes can be achieved in Monteggia-like lesions with Mason II and III fractures, when reconstruction is possible. Otherwise, RHA is a reliable option with satisfactory outcomes, especially in patients with ligamenteous instability. Whether the radial head should be excised remains debatable, although good results were achieved in patients with ligamentous stability and in those with complications after RHA. Cite this article: Bone Joint J 2019;101-B:1512–1519

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials. We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study. A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%). Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes

Introduction. There is renewed interest in dislocation after surgical approach with popularization of the direct anterior approach. The purported advantage of both the lateral and direct anterior approaches is decreased risk of dislocation. The purpose of this study was to assess the risk of dislocation by approach following modern primary THA. Methods. All primary THAs at a single academic institution from 2010 to 2017 were analyzed through our institutional total joint registry. There were 7023 THAs including 3754 posterior, 1732 lateral, and 1537 direct anterior. Risk of dislocation was assessed against the competing risks of revision surgery and death as well as by individual patient and surgical factors including surgical approach. Risk of revision surgery was considered as a secondary outcome. Step-wise selection was utilized to develop multivariable models. Clinical outcomes were documented with the Harris Hip Score (HHS). Mean age was 63 years, 51% were female, and mean body mass index (BMI) was 30 kg/m. 2. Minimum follow-up was 2 years. Results. The cumulative incidence of dislocation at 1-year and 5-years by approach was as follows: posterior (2.1%; 3.0%), lateral (0.7%; 0.7%), direct anterior (0.4%; 0.4%) (p<0.001) (Figure 1). Compared to the posterior cohort, the adjusted risk of dislocation was decreased for the lateral (hazard ratio [HR]=0.28, p<0.001) and direct anterior cohorts (HR=0.18, p<0.001). The cumulative incidence of revision for instability at 1-year and 5-years by approach was as follows: posterior (0.8%; 1.0%), lateral (0.6%; 0.6%), direct anterior (0%; 0%) (p=0.09). The adjusted risk of all-cause revision surgery was increased among the lateral cohort compared to posterior (HR=1.75, p=0.003) and direct anterior (HR=2.44, p=0.002) and among patients with diagnoses other than osteoarthritis (HR=2.89, p<0.001). Among patients who dislocated, 69 (83%) had anteversion >25° (Figure 2). Mean increase in HHS from preoperative assessment to final follow-up was greatest among direct anterior patients (37 points), followed by posterior patients (33 points), followed by lateral patients (29 points) (p<0.05, all comparisons). Conclusions. This study documents the risk of dislocation by surgical approach among a large contemporary cohort undergoing primary THA. The risk of dislocation was higher following the posterior approach, whereas all-cause revision surgery was found to be higher following the lateral approach. For any tables or figures, please contact the authors directly

Aims. The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis. Methods. A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated. Results. The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis. Conclusion. Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases. Level of evidence: II. Cite this article: Bone Jt Open 2021;2(12):1027–1034

Introduction. Several surgical approaches are available for elective total hip arthroplasty (THA) for osteoarthritis. While posterior surgical approaches are the most common, interest in a direct anterior (Hueter) approach is increasing because of alleged advantages in convalescence. However, no studies have examined differences in patient-reported global and condition-specific measures of health across multiple institutions. The ongoing Pulmonary Embolism Prevention after Hip and Knee Replacement (PEPPER) study is a PCORI-funded multicenter pragmatic clinical trial randomizing patients to three different antithrombotic regimens. We analyzed operative data from PEPPER to compare pre-post changes in validated patient-reported outcome measures after THA based on surgical approach. Methods. Participants (age 21 or older) were recruited from 27 academic medical centers for the PEPPER trial. Eligibility screening, baseline measures, and operative detail were entered into a central database with standardized blinded post-operative data collection protocol. We included participants undergoing elective primary total hip arthroplasty, excluding those undergoing revision, resurfacing, bilateral procedures, on chronic preoperative anticoagulation, with a recent history of gastrointestinal, cerebral, or other hemorrhage, defective hemostasis, or uncontrolled hypertension. Participating centers reported the operative approach as “Posterior”, “Transgluteal”, or “Anterior”. The brief version of the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS Jr.) and the Patient Reported Outcome Measurement Information System Global Survey (PROMIS10) were ascertained pre-operatively, and at 1, 3 and 6 months post-operatively. Mixed-effects linear regression was used to compare difference in patient-reported outcomes over time based on surgical approach, adjusting for baseline measures of health outcome, patient age, sex, race, ethnicity, BMI, comorbidity, education, work status, alcohol use, and smoking status. Results. As of 5/15/2018, a total of 1,238 patients had undergone primary THA as part of the PEPPER trial and were being monitored postoperatively, including 51.6% involving posterior, 18.1% transgluteal, and 30.3% anterior surgical approaches. Mean preoperative HOOS Jr. scores for posterior approach (47.6; 95%CI 46.4 – 48.7) were similar to transgluteal (47.4, 95%CI 45.4 – 49.5, p=0.654) and anterior (48.9, 95%CI 47.4 – 50.4, p=0.461) approaches. At 6-month follow-up, adjusted mean HOOS Jr. Scores significantly improved for all groups, but were not statistically different between groups. The adjusted mean HOOS Jr. score at 6 months was 85.6 for those undergoing a posterior (95%CI 83.7 – 87.5), 83.6 for transgluteal (95%CI 79.0 – 88.2, p=.474) and 85.0 for anterior approaches (95%CI 82.6 – 87.5, p=0.255). Baseline PROMIS-10 Physical Function scores were similar between posterior (40.1; 95%CI 40.2 – 41.3), transgluteal (40.6, 95%CI 39.6 – 41.6, p=0.716), and anterior approaches (41.5, 95%CI 40.8 – 42.3, p=0.390), with similar postoperative improvement through 6 months (posterior=52.1, 95%CI 51.2 – 53.0; transgluteal=52.4, 95%CI 50.2 – 54.5, p=0.734; anterior=52.8, 95%CI 51.6 – 53.9, p=0.414). These findings were robust utilizing a variety of methods to account for missing responses. Conclusion. We found similar short-term improvements in patient-reported global measures of health between posterior, transgluteal, and anterior surgical approaches for elective THA, and a trend suggesting inferior early patient-reported measures of function with a trans-gluteal surgical approach

Aims. Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study’s purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length. . Patients and Methods. This was a retrospective investigation from two centres and seven surgeons (three DA, three PL, one both) of primary THAs. PL patients were categorized for incision length (6 cm to 8 cm, 8 cm to 12 cm, 12 cm to 15 cm). All patients had cementless femoral and acetabular fixation, at least one year’s follow-up, and well-fixed components. Patients completed a pain-drawing questionnaire identifying the location and intensity of pain on an anatomical diagram. Power analysis indicated 800 patients in each cohort for adequate power to detect a 4% difference in pain (alpha = 0.05, beta = 0.80). Results. A total of 1848 patients (982 DA, 866 PL) were included. PL patients were younger (59.4 years, . sd. 12.9 vs 62.7 years, . sd. 9.7; p < 0.001) and had shorter follow-up (3.3 years, . sd. 1.3 vs 3.7 years, . sd. 1.3; p < 0.001). DA patients reported decreased moderate to severe trochanteric (14% vs 21%; p < 0.001) and groin pain (19% vs 24%; p = 0.004) than PL patients. There were no differences in anterior, lateral, or posterior thigh, back, or buttock pain between cohorts (p = 0.05 to 0.7). PL approach incision length did not impact the incidence or severity of pain (p = 0.3 to 0.7). Conclusion. A significant proportion of patients perceive persistent pain following THA regardless of approach. DA patients reported less trochanteric and groin pain versus PL patients. PL incision length did not influence the incidence or severity of patient-reported pain. Cite this article: Bone Joint J 2019;101-B(6 Supple B):31–36

We undertook a randomised controlled trial to compare the piriformis-sparing approach with the standard posterior approach used for total hip replacement (THR). We recruited 100 patients awaiting THR and randomly allocated them to either the piriformis-sparing approach or the standard posterior approach. Pre- and post-operative care programmes and rehabilitation regimes were identical for both groups. Observers were blinded to the allocation throughout; patients were blinded until the two-week assessment. Follow-up was at six weeks, three months, one year and two years. In all 11 patients died or were lost to follow-up.

There was no significant difference between groups for any of the functional outcomes. However, for patients in the piriformis-sparing group there was a trend towards a better six-minute walk test at two weeks and greater patient satisfaction at six weeks. The acetabular components were less anteverted (p = 0.005) and had a lower mean inclination angle (p = 0.02) in the piriformis-sparing group. However, in both groups the mean component positions were within Lewinnek’s safe zone. Surgeons perceived the piriformis-sparing approach to be significantly more difficult than the standard approach (p = 0.03), particularly in obese patients.

In conclusion, performing THR through a shorter incision involving sparing piriformis is more difficult and only provides short-term benefits compared with the standard posterior approach.

Aims. Hemiarthroplasty of the hip is usually carried out through either a direct lateral or posterior approach. The aim of this prospective observational study was to determine any differences in patient-reported outcomes between the two surgical approaches. . Patients and Methods. From the Swedish Hip Arthroplasty Register we identified patients of 70 years and above who were recorded as having had a hemiarthroplasty during 2009. Only patients who had been treated with modern prostheses were included. A questionnaire was posted to those who remained alive one year after surgery. A total of 2118 patients (78% of those available) with a mean age of 85 years (70 to 102) returned the questionnaire. . Results. Patients who had undergone surgery through a posterior approach reported a higher health-related quality of life (HRQoL, EQ-5D mean 0.52 versus 0.47, p = 0.009), less pain (visual analogue scale mean 17 versus 19, p = 0.02) and greater satisfaction with the result of surgery (visual analogue scale mean 22 versus 24, p = 0.02) than those who had a direct lateral approach. However, after adjusting for age, gender, cognitive impairment and American Society of Anesthesiologists grade, no association was found between surgical approach and HRQoL, residual pain or patient satisfaction. Take home message: The surgical approach for hemiarthroplasty does not seem to affect the patient-perceived HRQoL, residual pain or patient satisfaction one year after surgery on elderly patients. The choice of approach should be based on other factors, such as the risk of dislocation. Cite this article: Bone Joint J 2016;98-B:542–7

The effectiveness of total hip replacement as a surgical intervention has revolutionized the care of degenerative conditions of the hip joint. However, the surgeon is still left with important decisions in regards to how best deliver that care with choice of surgical approach being one of them especially in regards to the short-term clinical outcome. It is however unclear if a particular surgical approach offers a long-term advantage. This study aims to determine the influence of the three main surgical approaches to the hip on patient reported outcomes and quality of life after 5 years post-surgery. We extracted from our prospective database all the patients who underwent a Total Hip Replacement surgery for osteoarthritis or osteonecrosis between 2008 and 2012 by an anterior, posterior or lateral approach. All the pre-operative and post-operative HOOS (Hip disability and Osteoarthritis Outcome Score) and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scores were noted. Analysis of covariance (ANCOVAs) were used to study the relationship between amount of change in HOOS and WOMAC subscales (dependant variables) and approach used, by also including confounding factors of age, gender, ASA (American Society of Anaesthesiologists) score, Charnley score and Body Mass Index. A total of 1895 patients underwent a primary total hip arthroplasty during the considered period. Among them, 367 had pre-operative and ≥5 years post operative PROM scores (19.47%). The mean follow-up for the study cohort was 5.3 years (range 5 to 7 years) with, 277 at 5 years, 63 at 6 years, and 27 at 7 years. In the posterior approach group we had 138 patients (37.60%), 104 in the lateral approach (28.34%) and 125 in the anterior approach (34.06%). There were no significant differences between the 3 groups concerning the Charnley classification, BMI, Gender, ASA score, side and pre-operative functional scores. We did not observe any significant difference in the amount of change in HOOS and WOMAC subscales between the 3 groups. There were no differences either in the post-operative scores in ultimate value. Our monocentric observational study shows that these three approaches provide predictable and comparable outcomes on HRQL and PROMs at long-term follow-up both in terms of final outcome but also in percent improvement. This study has several limitations. We excluded patients who underwent revision surgery leaving the unanswered question of how choice of surgical approach could lead to different revision rates, which have an impact on the functional outcomes. Moreover, even if we controlled for the most important confounders by a multivariate analysis model, there is still some involved cofounders, which could potentially lead to a bias such as smoking, socio-economical status or femoral head diameter. But we do not have any reason to think that these parameters could be unequally distributed between the three groups. Finally, our study cohort represents of 19.47% of the complete cohort. The fact that not all patients have PROM's was pre-determined as eight years ago we instituted that only 1 in 5 patients that returned their pre-operative questionnaire would get their PROM's at follow-up. Despite this, our statistical power was sufficient