Aims. Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England. Methods. We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA. Results. We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018. Conclusion. Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care. Cite this article: Bone Joint J 2022;104-B(9):1052–1059

Aims. To investigate whether chronic kidney disease (CKD) is associated with the risk of all-cause revision or revision due to a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty. Methods. This retrospective cohort study comprised 18,979 consecutive hip and knee arthroplasties from a single high-volume academic hospital. At a median of 5.6 years (interquartile range (IQR) 3.5 to 8.1), all deaths and revisions were counted. To overcome the competing risk of death, competing risk analysis using the cumulative incidence function (CIF) was applied to analyze the association between different stages of CKD and revisions. Confounding factors such as diabetes and BMI were considered using either a stratified CIF or the Fine and Gray model. Results. There were 2,111 deaths (11.1%) and 677 revisions (3.6%) during the follow-up period. PJI was the reason for revision in 162 cases (0.9%). For hip arthroplasty, 3.5% of patients with CKD stage 1 (i.e. normal kidney function, NKF), 3.8% with CKD stage 2, 4.2% with CKD stage 3, and 0% with CKD stage 4 to 5 had undergone revision within eight years. For knee arthroplasty, 4.7% with NKF, 2.7% with CKD stage 2, 2.4% with CKD stage 3, and 7% of CKD stage 4 to 5 had had undergone revision. With the exception of knee arthroplasty patients in whom normal kidney function was associated with a greater probability of all-cause revision, there were no major differences in the rates of all-cause revisions or revisions due to PJIs between different CKD stages. The results remained unchanged when diabetes and BMI were considered. Conclusion. We found no strong evidence that CKD was associated with an increased risk of all-cause or PJI-related revision. Selection bias probably explains the increased amount of all-cause revision operations in knee arthroplasty patients with normal kidney function. The effect of stage 4 to 5 CKD was difficult to evaluate because of the small number of patients. Cite this article: Bone Joint J 2021;103-B(4):689–695

We undertook a study to determine the rates of infection and revision of total knee replacement (TKR) in patients with renal failure, renal transplantation and those undergoing renal dialysis in Scotland. The overall early and late infection rates were 1.10% and 2.19% compared with 1.06% and 2.01%, respectively, for non-renal patients. Patients with renal failure had a significantly increased risk of early infection (1.6%, relative risk 1.52, p = 0.002) and late infection (4.47%, relative risk 2.22, p < 0.001). Those on renal dialysis had significantly increased risks of late infection (8.03%, relative risk 3.99, p < 0.001) and early revision (3.70%, relative risk 4.40, p < 0.001). Renal transplant patients had a significantly increased risk of late infection, regardless of whether renal transplantation occurred before TKR (9.09%, relative risk 4.517, p = 0.027) or at any time (8.0%, relative risk 3.975, p = 0.047). There were significantly increased rates of comorbidities associated with infection for all the renal patient groups. Logistic regression analysis showed that renal failure and renal dialysis were independent risk factors for early infection and revision, respectively.

ERAS (Enhanced recovery after surgery) programs have been widely adopted in elective orthopaedic practice. Early discontinuation of Intravenous (IV) fluids in order to promote mobilisation and subsequent discharge is a key feature of such programs. However concerns have been raised regarding whether such an approach results in an increased risk of acute kidney injury (AKI).

We set out to determine the incidence of AKI in patients undergoing hip or knee arthroplasty treated as part of an ERAS program where IV fluids are removed before leaving the recovery room. Investigate whether there is a difference in incidence between patients with a pre-operative eGFR ≥ 60 or < 60 (ml/min/1.73m2). In addition to whether patients who sustain an AKI have a longer post-operative hospital stay.

The pre and post-operative blood results of patients undergoing elective total hip and total knee replacements were retrospectively analysed to determine whether they had suffered an AKI during admission. The patient's notes were reviewed for other known causes of peri-operative AKI and the length of their hospital stay.

The overall Incidence of AKI was 9.4%. There was a significant association found between pre-operative eGFR and development of an AKI p = 0.002. The incidence of AKI was 5.8% in patients with a pre-operative eGFR ≥ 60 vs 33.3% in those with an eGFR < 60. The development of an AKI was associated with a longer hospital stay p = 0.042. The median length of hospital stay was 7 days for those who suffered an AKI vs 5 days for those who did not.

Patients undergoing elective lower limb arthroplasty with a pre-operative eGFR < 60 treated as part of an ERAS program where fluids are discontinued before leaving the recovery room are at high risk of developing an AKI. Further studies are required to ascertain whether a longer duration of IV fluids is effective in reducing the incidence of AKI in this group.

Renal Osteodystrophy is a type of metabolic bone disease characterized by bone mineralization deficiency due to electrolyte and endocrine abnormalities. Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. Treatment involves medical management to resolve the etiology of the underlying renal condition, as well as management (and prevention) of pathological fractures. A 66-year-old female patient, with severe osteoporosis and chronic kidney disease undergoing haemodialysis, has presented with multiple fractures along the years. She was submitted to bilateral proximal femoral nailing as fracture treatment on the left and prophylactically due to pathological bone injury on the right, followed by revision of the left nail with a longer one after varus angulation and fracture distal to the nail extremity. Meanwhile, the patient suffered a pathological fracture of the radial and cubital diaphysis and was submitted to conservative treatment with cast, with consolidation of the fracture. Posteriorly, she re-fractured these bones after a fall and repeated the conservative treatment. Clinical management: There is a multidisciplinary approach to manage the chronic illness of the patient, including medical management to resolve the etiology and consequences of her chronic kidney disease, pain control, conservative or surgical fracture management and prevention of falls. The incidence of chronic renal disease is increasing and the patients with this condition live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Their quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. A multidisciplinary approach is required to treat these patients, controlling their chronic diseases, managing fractures and preventing falls

Aim. Chronic bone infections and infected fractures are often treated with excision of the dead bone and implantation of biomaterials which elute antibiotics. Gentamicin has been a preferred drug for local delivery, but this could induce renal dysfunction due to systemic toxicity. This is a particular concern in patients with pre-existing chronic renal disease treated with new antibiotic carriers which achieve very high peak levels of gentamicin in the first few days after surgery. Method. 163 patients (109 males; average age 51.6 years) with Cierny-Mader Type 3 or 4 chronic osteomyelitis had a single-stage operation with excision of the dead bone, filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier, containing gentamicin and immediate soft tissue closure. 2. No patient was given systemic gentamicin or other renal toxic antibiotics. Mean carrier volume was 10.9mls (range 1–30mls) and mean gentamicin dosing was 190.75mg (maximum 525mg). Seven patients had pre-existing renal disease (4 diabetic nephropathy, 1 nephrotic syndrome, 1 renal transplant and 1 previous acute kidney injury). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Glomerular filtration rate (GFR) was calculated using the CKD-epi creatinine equation. Renal function was defined using the Chronic Kidney Disease (CKD) Staging system. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. Pre-operative CKD staging demonstrated 118 Class I (normal renal function), 30 Class II, 3 Class IIIa, 3 Class IIIb, and 1 Class V disease. Mean pre-operative GFR (99.7ml/min/1.73m. 2. , SD 21.0) was no different to post-operative GFR (103.2ml/min/1.73m. 2. , SD 21.3), p= 0.0861. Four cases had a >10% decline in GFR below normal, with only one case dropping a CKD stage, from I (normal) to II (mildly decreased). Only 1/7 cases with pre-existing renal disease had a GFR drop of >10% (from 11ml/min/1.73m. 2. to 8ml/min/1.73m. 2. ). 70/155 (45.2%) had a temporary GFR drop post-operatively, with the biggest drop occurring a mean 3.06 days following surgery (SD 2.1). No patient had clinical signs of new acute renal impairment post-operatively. Conclusions. Renal function is not significantly affected by local implantation of gentamicin up to 525mg. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy

Aims. This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification. Methods. We conducted a retrospective analysis of 162 knees (162 patients) that received treatment for PJI post-TKA with combined IV and topical antibiotic infusions at a single academic hospital from 1 January 2010 to 31 December 2022. The incidence of AKI was evaluated using the KDIGO criteria, focussing on the identification of significant predictors and the temporal pattern of AKI development. Results. AKI was identified in 9.26% (15/162) of the cohort, predominantly presenting as stage 1 AKI, which was transient in nature and resolved prior to discharge. The analysis highlighted moderate anaemia and lower baseline serum creatinine levels as significant predictors for the development of AKI. Notably, the study found no instances of severe complications such as wound dehiscence, skin erosion, or the need for haemodialysis following treatment. Conclusion. The findings suggest that the combined use of IV and topical antibiotic therapy in the management of PJIs post-TKA is associated with a low incidence of primarily transient stage 1 AKI. This indicates a potentially favourable renal safety profile, advocating for further research to confirm these outcomes and potentially influence treatment protocols in PJI management. Cite this article: Bone Joint Res 2024;13(10):525–534

Aims. The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?. Methods. PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments. Results. From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture. Conclusion. Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making. Cite this article: Bone Joint Res 2023;12(2):103–112

Aims. Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. Methods. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA. Results. Orthopaedic surgeons evaluated patients with a mean HCC of 1.21, while neurosurgeons evaluated patients with a mean HCC of 1.34 (p < 0.05). The rates of specific comorbidities in patients seen by orthopaedic surgeons/neurosurgeons is as follows: Ischemic heart disease (35%/39%), diabetes (31%/33%), depression (23%/31%), chronic kidney disease (19%/23%), and heart failure (17%/19%). Conclusion. Nationally, comorbidity rate and HCC value for these Medicare patients are higher than national averages for the US population, with ischemic heart disease being six-times higher, diabetes two-times higher, depression three- to four-times higher, chronic kidney disease three-times higher, and heart failure nine-times higher among patients evaluated by orthopaedic surgeons and neurosurgeons. Cite this article: Bone Joint Open 2020;1-6:257–260

Introduction. The treatment of chronic bone infection often involves excision of dead bone and implantation of biomaterials which elute antibiotics. Gentamicin is a preferred drug for local delivery, but its systemic use carries a well-established risk of nephrotoxicity. We aim to establish the risk of renal injury with local delivery in a ceramic carrier. Materials and Methods. 163 consecutive patients with Cierny-Mader Type 3 or 4 chronic osteomyelitis were treated with a single-stage operation which included filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier containing gentamicin. The mean carrier volume used was 10.9mls, leading to a mean implanted gentamicin dose of 191.3mg (maximum 525mg). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Renal impairment was graded using the Chronic Kidney Disease (CKD) Staging system, and AKI was assessed using the RIFLE criteria. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. 7 patients had pre-existing renal disease. 70 patients (45.2%) had a temporary eGFR drop post-operatively, with the greatest decrease occurring a mean 3.06 days following surgery. Twenty cases had a >10% decline in eGFR, but 12 resolved within 7 days. 7 patients transiently fell into the “Risk” category according to RIFLE criteria, but no patient had a change consistent with “Injury”, “Failure” or “Loss” of renal function and none had clinical signs of new acute renal impairment post-operatively. Conclusions. The implantation of up to 525mg of gentamicin contained within Cerament G, as part of the surgical treatment of osteomyelitis, is safe and carries minimal risk of significant acute kidney injury. A small, transient increase in serum creatinine may be observed in the early post-operative period, and attention should be paid to limit patients exposure to other nephrotoxic agents. The majority of patients will return to their baseline renal function within 7 days following the operation. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy

Aims. Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods. We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results. Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion. We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351

Aims. The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome. Methods. A retrospective review was performed of consecutive patients treated for HA PJI at a tertiary referral centre with a mean 4.5 years’ follow-up (1.6 weeks to 12.9 years). Surgeries performed included debridement, antibiotics, and implant retention (DAIR) and single-stage revision. The effect of different factors on developing infection and treatment outcome was determined. Results. A total of 1,984 HAs were performed during the study period, and 44 sustained a PJI (2.2%). Multiple logistic regression analysis revealed that a higher CCI score (odds ratio (OR) 1.56 (95% confidence interval (CI) 1.117 to 2.187); p = 0.003), peripheral vascular disease (OR 11.34 (95% CI 1.897 to 67.810); p = 0.008), cerebrovascular disease (OR 65.32 (95% CI 22.783 to 187.278); p < 0.001), diabetes (OR 4.82 (95% CI 1.903 to 12.218); p < 0.001), moderate-to-severe renal disease (OR 5.84 (95% CI 1.116 to 30.589); p = 0.037), cancer without metastasis (OR 6.42 (95% CI 1.643 to 25.006); p = 0.007), and metastatic solid tumour (OR 15.64 (95% CI 1.499 to 163.087); p = 0.022) were associated with increasing PJI risk. Upon final follow-up, 17 patients (38.6%) failed initial treatment and required further surgery for HA PJI. One-year mortality was 22.7%. Factors associated with treatment outcome included lower preoperative Hgb level (97.9 g/l (SD 11.4) vs 107.0 g/l (SD 16.1); p = 0.009), elevated CRP level (99.1 mg/l (SD 63.4) vs 56.6 mg/l (SD 47.1); p = 0.030), and type of surgery. There was lower chance of success with DAIR (42.3%) compared to revision HA (66.7%) or revision with conversion to total hip arthroplasty (100%). Early-onset PJI (≤ six weeks) was associated with a higher likelihood of treatment failure (OR 3.5 (95% CI 1.2 to 10.6); p = 0.007) along with patients treated by a non-arthroplasty surgeon (OR 2.5 (95% CI 1.2 to 5.3); p = 0.014). Conclusion. HA PJI initially treated with DAIR is associated with poor chances of success and its value is limited. We strongly recommend consideration of a single-stage revision arthroplasty with cemented components. Cite this article: Bone Jt Open 2022;3(12):924–932

Aims. We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). Methods. This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na. +. ), potassium (K. +. ), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported. Results. The study included 2,721 patients with a mean age of 69 years, of whom 1,266 (46.6%) were male. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥ 65 years), female sex, and ASA grade ≥ III as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dl) and packed cell volume (≤ 0.395 l/l) were noted to be significant risk factors for postoperative anaemia, and potassium (≤ 3.7 mmol/l) was noted to be a significant risk factor for AKI. Conclusion. The costs outweigh the benefits of ordering routine postoperative blood tests in TJR patients. Clinicians should risk-stratify their patients and have a lower threshold for ordering blood tests in patients with abnormal preoperative haemoglobin (≤ 127 g/l), blood loss > 300 ml, chronic kidney disease, ASA grade ≥ III, and clinical concern. Cite this article: Bone Jt Open 2023;4(11):899–905

Aims. To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage. Methods. We included 53,099 patients with cemented THA due to osteoarthritis from the Swedish Hip Arthroplasty Registry for model derivation and internal validation, as well as 125,428 patients from England and Wales recorded in the National Joint Register for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey (NJR) for external model validation. A model was developed using a bootstrap ranking procedure with a least absolute shrinkage and selection operator (LASSO) logistic regression model combined with piecewise linear regression. Discriminative ability was evaluated by the area under the receiver operating characteristic curve (AUC). Calibration belt plots were used to assess model calibration. Results. A main effects model combining age, sex, American Society for Anesthesiologists (ASA) class, the presence of cancer, diseases of the central nervous system, kidney disease, and diagnosed obesity had good discrimination, both internally (AUC = 0.78, 95% confidence interval (CI) 0.75 to 0.81) and externally (AUC = 0.75, 95% CI 0.73 to 0.76). This model was superior to traditional models based on the Charlson (AUC = 0.66, 95% CI 0.62 to 0.70) and Elixhauser (AUC = 0.64, 95% CI 0.59 to 0.68) comorbidity indices. The model was well calibrated for predicted probabilities up to 5%. Conclusion. We developed a parsimonious model that may facilitate individualized risk assessment prior to one of the most common surgical interventions. We have published a web calculator to aid clinical decision-making. Cite this article: Bone Joint J 2021;103-B(3):469–478

Aims. The primary aim of this study was to assess whether non-fatal postoperative venous thromboembolism (VTE) within six months of surgery influences the knee-specific functional outcome (Oxford Knee Score (OKS)) one year after total knee arthroplasty (TKA). Secondary aims were to assess whether non-fatal postoperative VTE influences generic health and patient satisfaction at this time. Methods. A study of 2,393 TKAs was performed in 2,393 patients. Patient demographics, comorbidities, OKS, EuroQol five-dimension score (EQ-5D), and Forgotten Joint Score (FJS) were collected preoperatively and one year postoperatively. Overall patient satisfaction with their TKA was assessed at one year. Patients with VTE within six months of surgery were identified retrospectively and compared with those without. Results. A total of 37 patients (1.5%) suffered a VTE and were significantly more likely to have associated comorbidities of stroke (p = 0.026), vascular disease (p = 0.026), and kidney disease (p = 0.026), but less likely to have diabetes (p = 0.046). In an unadjusted analysis, patients suffering a VTE had a significantly worse postoperative OKS (difference in mean (DIM) 4.8 (95% confidence interval (CI) 1.6 to 8.0); p = 0.004) and EQ-5D (DIM 0.146 (95% CI 0.059 to 0.233); p = 0.001) compared with patients without a VTE. After adjusting for confounding variables VTE remained a significant independent predictor associated with a worse postoperative OKS (DIM -5.4 (95% CI -8.4 to -2.4); p < 0.001), and EQ-5D score (DIM-0.169 (95% CI -0.251 to -0.087); p < 0.001). VTE was not independently associated with overall satisfaction after TKA (odds ratio 0.89 (95% CI 0.35 to 2.07); p = 0.717). Conclusion. Patients who had a VTE within six months of their TKA had clinically significantly worse knee-specific outcome (OKS) and general health (EQ-5D) scores one year postoperatively, but the overall satisfaction with their TKA was similar to those patients who did not have a VTE. Cite this article: Bone Joint J 2021;103-B(7):1254–1260

Background. Post-operative acute kidney injury is significant complication following surgery. Patients who develop AKI have an increased risk for progression into chronic kidney disease, end-stage renal failure and increased mortality risk. The patient outcomes following total knee replacement (TKR), who develop AKI has been a topic of interest in recent years as it may have patient and medicolegal implications. Nevertheless, there are no studies looking at the incidence, risk factors and outcomes of AKI following bilateral TKRs at the same sitting. Objectives. To determine the incidence, risk factors and outcomes of post-operative AKI following bilateral TKRs surgery at the same sitting. Methods. This was a retrospective single-centre study performed at the Princess Royal Hospital, which performed a total of 25 BTKR. The incidence, Surgical and patient risk factors were recorded and analysed. Results. The incidence of AKI as defined by NICE guidelines following bilateral TKRs was 20%. 16% (4 patients) had stage 1 and 4% (1 patient) had stage 2 AKI. The mean change in Creatinine between pre- and post-operative blood tests was +19μmol/L. There was a strong significant correlation between CKD and AKI (r=0.75, P<0.05). Furthermore, a moderate correlation was found between higher BMI and pre-operative Charlson index and AKI. AKI did not have an effect on the length of inpatient stay with the mean inpatient length of stay for patients who had an AKI of 10 days compared to 11days for those who did not. All AKIs were resolved within 72 hours. There were no associated mortalities with AKI. Conclusion. The incidence of AKI following bilateral TKR was 20%. Pre-operative chronic kidney disease as well as having a higher BMI were identified as risk factors for developing AKI. Pre-operative CKD optimisation and careful adequate hydration intra-operatively should be considered in these patients. AKI was not associated with an increased length of stay or mortality in our study

To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic lower back pain. This prospective cohort study was conducted from 20th March 2017 to 19th March 2019. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months. A total of 600 patients were included in the study. The mean age of patients was 44.2 ± 11.92 years. There were 337 (56.2%) male patients while 263 (43.8%) female patients. Baseline mean vitamin-D levels were 13.32 ± 6.10 ng/mL and increased to 37.18 ± 11.72 post supplementation (P < 0.0001). There was a significant decrease in the pain score after 2nd, 3rd& 6th months (61.7 ± 4.8, 45.2 ± 4.6 & 36.9 ± 7.9, respectively) than 81.2 ± 2.4 before supplementation (P < 0.001). The modified Oswestry disability score also showed significant improvement after 2nd, 3rd & 6th months (35.5, 30.2 & 25.8, respectively) as compared to baseline 46.4 (P < 0.001). About 418 (69.7%) patients attained normal levels after 6 months. Vitamin-D supplementation in chronic lower back pain patients may lead to improvement in pain intensity and functional ability

Prosthetic joint infections (PJI) are devastating complications. Our knowledge on hip fractureassociated hemiarthroplasty PJI (HHA-PJI) is limited compared to elective arthroplasty. The goal of this study was to describe the epidemiology, risk factors, management, and outcomes for HHA-PJI. A population-based (465,000) multicentre retrospective analysis of HHAs between 2006-2018 was conducted. PJI was defined by international consensus and treatment success as no return to theatre and survival to 90 days after the initial surgical management of the infection. Univariate, survival and competing risk regression analyses were performed. 1852 HHAs were identified (74% female; age:84±7yrs;90-day-mortality:16.7%). Forty-three (2.3%) patients developed PJI [77±10yrs; 56% female; 90-day-mortality: 20.9%, Hazard-Ratio 1.6 95%CI 1.1-2.3,p=0.023]. The incidence of HHA-PJI was 0.77/100,000/year and 193/100,000/year for HHA. The median time to PJI was 26 (IQR 20-97) days with 53% polymicrobial growth and 41% multi-drug resistant organisms (MDRO). Competing risk regression identified younger age [Sub-Hazard-Ratio(SHR) 0.86, 95%CI 0.8-0.92,p<0.001], chronic kidney disease (SHR 3.41 95%CI 1.36-8.56, p=0.01), body mass index>35 (SHR 6.81, 95%CI 2.25-20.65, p<0.001), urinary tract infection (SHR 1.89, 95%CI 1.02-3.5, p=0.04) and dementia (SHR 9.4, 95%CI 2.89-30.58,p<0.001) as significant risk factors for developing HHA-PJI. When infection treatment was successful (n=15, 38%), median survival was 1632 days (IQR 829-2084), as opposed to 215 days (IQR 20-1245) in those who failed, with a 90-day mortality of 30%(n=12). There was no significant difference in success among debridement, excision arthroplasty or revision arthroplasty. HHA PJI is uncommon but highly lethal. All currently identified predictors are non-modifiable. Due to the common polymicrobial and MDRO infections our standard antibiotic prophylaxis may not be adequate HHA-PJI is a different disease compared to elective PJI with distinct epidemiology, pathogens, risk factors and outcomes, which require targeted research specific to this unique population

Aim. Prosthetic joint infection (PJI) is a devastating and costly complication of total joint arthroplasty (TJA). Use of extended oral antibiotic prophylaxis (EOAP) has become increasingly popular in the United States following a highly publicized study (Inabathula et al) from a single center demonstrating a significant protective effect (81% reduction) against PJI in ‘high-risk’ patients. However, these results have not been reproduced elsewhere and EOAP use directly conflicts with current antibiotic stewardship efforts. In order to study the role of EOAP in PJI prevention, consensus is needed for what defines ‘high-risk’ patients. The revision TJA (rTJA) population is an appropriate group to study due to having a higher incidence of PJI. The purpose of the current study was to rigorously determine which preoperative conditions described by Inabathula et al. (referred to as Inabathula criteria (IBC)) confer a higher rate of PJI in patients undergoing aseptic rTJA. Method. 2,256 patients that underwent aseptic rTJA at a single high-volume institution between 2016–2022 were retrospectively reviewed. Patient demographics and comorbidities were recorded to determine if they had 1 or more ‘IBC’, a long list of preoperative conditions including autoimmune diseases, active smoking, body mass index (BMI)>35, diabetes mellitus, and chronic kidney disease (CKD). Reoperation for PJI at 90-days and 1-year was recorded. Chi-squared or Fischer's exact tests were calculated to determine the association between preoperative presence/absence of IBC and PJI. Multivariable logistic regressions were conducted to determine if specific comorbidities within the IBC individually conferred an increased PJI risk. Results. 1223 patients (54.2%) had at least one IBC condition. IBC-positive patients were more likely to be female, have an increased ASA score, and higher BMI. IBC-positive patients had a significant increase in PJI risk at both 90-days (relative risk (RR)=2.32, p<0.0001) and 1-year (RR=2.14, p=0.002) versus IBC-negative patients. Within IBC-positive patients, every additional IBC condition conferred a 1.8× odds increase for 90-day PJI (p<0.0001), and 1.76× odds increase in 1-year PJI (p<0.0001). Multivariable logistic regression identified active smoking, BMI>35, CKD, and diabetes mellitus as being independently associated with PJI development (p<0.05). Conclusions. Over half of rTJA patients meet IBC and could be eligible to receive EOAP in the United States. However, the specific presence of active smoking, BMI>35, CKD, and diabetes mellitus appear to be responsible for the increased risk of PJI. Prospective studies investigating EOAP use for patients with these specific conditions are urgently needed to prevent unnecessary antibiotic use

Aim. Sepsis is a life-threatening complication of periprosthetic joint infections (PJI) that requires early and effective therapy. This study aims to investigate the epidemiology, associated risk factors, and outcome of sepsis in the context of periprosthetic joint infections (PJI). Method. This single-center retrospective cohort study included patients treated for PJI from 2017 to 2020. Patients were classified based on the criteria of the European Bone and Joint Infection Society. The presence of sepsis was determined using the SOFA score and SIRS criteria. The cohort with PJI and sepsis (sepsis) was compared to patients with PJI without sepsis (non-sepsis). Risk factors considered were patient characteristics, affected joints, surgical therapy, microbiological findings, preexisting medical conditions, clinical symptoms, and symptom duration. Outcome parameters were mortality, length of hospital stay, and length of stay in the intensive care unit. Results. A total of 109 patients with PJI were identified, of whom 45 patients (41.3%) met the criteria for sepsis. Patients with sepsis had more severe preexisting diseases compared with the non-sepsis cohort (Charlson Comorbidity Index 3.8 vs. 2.8; p≤0.001). An increased odds ratio (OR) for a septic course was found for the comorbidities pneumonia (8.2; p=0.001), myocardial infarction (2.0; p=0.02), atrial fibrillation (3.3; p=0.01), diabetes mellitus (1.2; p=0.04), endocarditis (5.5; p=0.01), and renal disease (2.0; p≤0.001). Infection with Staphylococcus aureus (sepsis 20 vs. non-sepsis 10; p=0.002), Streptococcus dysgalactiae (sepsis 7 vs. non-sepsis 2; p=0.002) and Candida albicans (sepsis 5 vs. non-sepsis 0; p=0.01) were more prevalent in patients with sepsis. In the sepsis cohort, further infectious foci were present in addition to PJI in 57.8% of patients, compared to 18.8% in the non-sepsis cohort. The presence of sepsis was associated with a longer hospital stay (sepsis 68 days vs. non-sepsis 38 days; p=0.001) and longer intensive care unit stay (sepsis 12 days vs. non-sepsis 2 days; p=0.001). In-hospital mortality was ten times higher in the sepsis cohort compared to non-septic patients (sepsis 11/42 vs. non-sepsis 2/64; OR 10.3; p=0.01). Conclusions. In a relevant proportion of patients, PJI can lead to a septic course of disease associated with increased mortality. Particularly in patients with preexisting diseases, increased attention is required, and comprehensive screening for other foci of infection seems mandatory. In addition to highly virulent pathogens such as staphylococci and streptococci, fungal infections should be considered as causative pathogens in septic patients with PJI