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 burden of hospital length of stay (LOS) and readmissions for total hip arthroplasty (THA) patients has resulted in great scrutiny. The purpose of this study was to determine our patients' LOS and hospital readmissions over the past 7 years. The second purpose was to determine what comorbidities affected the LOS and readmissions of 1440 THA patients. 1440 THA patients were retrospectively reviewed. The group included 622 males, 818 females. The average age of the cohort was 60 years (12 to 94 years). Ninety-day hospital readmissions were measured for the patients. Fisher's exact test, independent Sample t-test and Spearman correlation coefficients were used to determine associations of patient characteristics and comorbidities with readmission status and LOS with comorbidity status. The LOS decreased over the time of the study (p=0.02), however; readmissions remained constant at approximately 6% (p=0.73). The mean LOS for patients not readmitted was significantly shorter than for those readmitted (3.2 vs. 4.4 days; p=0.0003). Comorbidities associated with a longer hospital stay included diabetes (p=0.0052), hypertension (p=0.04), coronary artery disease (p=0.0034), congestive heart failure (p=0.0012), peripheral vascular disease (p=0.015), chronic obstructive pulmonary disease (p=0.016), renal disease (p=0.009), and mental illness (p=0.03). Increased body mass index (BMI) was not associated with a significant increase in LOS (r=0.01, p=0.83). Increased readmission rates were associated with comorbidities including hypertension (p=<0.0001), coronary artery disease (p=<0.0001), congestive heart failure (p=0.0007), peripheral vascular disease (p=<0.0001), chronic obstructive pulmonary disease (p=0.003), asthma (p=0.0128), renal disease (p=0.0001), and mental illness (p=0.0147). Obesity was not associated with increased readmission rates until the patients were morbidly obese (>40 BMI; p=0.03). Although the LOS decreased over the time of the study, this did not result in an adverse increase in readmission rates. Several comorbidities including hypertension, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, and mental illness were all associated with both a longer LOS and an increase in readmission rates. Asthma was associated with increased readmission rates only and diabetes was associated with an increased LOS only. BMI was not associated with readmission rates unless the BMI exceeded 40 and had no significant effect on LOS at any BMI level

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

Given the high prevalence of psychiatric illness in the total joint arthroplasty (TJA) population, relatively little is known about how these two conditions affect each other. Therefore, the purpose of this study is to evaluate the role of major psychiatric illness on patient specific outcomes after TJA. We hypothesize that patients with major psychiatric illnesses will report inferior outcomes and have more complications after TJA compared to those without any psychiatric illness. We matched and compared two cohorts of patients undergoing TJA from a prospectively collected database registry, which included those with and without a major psychiatric disorder. Major psychiatric disorder was identified in the registry database by determining if patients had been formally diagnosed with any of the following conditions: bipolar disorder, major personality disorder, chronic mental health diagnoses, depression, or schizophrenia. Primary outcomes of interest included patient specific outcomes measured using the WOMAC or EQ5D. Secondary outcomes included complications, infections, hospital length of stay, 30-day readmission rates and final discharge destination. In total we included 1828 TJAs (1000 THAs, 828 TKAs). In terms of the primary outcome, both the THA experimental group (37.80 ± 17.91 vs. 40.74 ± 19.3, p=0.023) and TKA experimental group (43.38 ± 18.41 vs 45.45 ± 20.07, p=0.050) had significantly lower preoperative WOMAC scores compared to their respective control groups. At the 3-month period both the THA experimental group (76.74 ± 16.94 vs. 79.16 ± 16.19, p=0.036) and TKA experimental group (71.09 ± 18.64 vs. 75.92 ± 16.22, p=0) again had significantly lower 3-month postoperative WOMAC score. Clinical outcomes at the 1-year mark were similar for both groups in terms of WOMAC and EQ5D. Patients with psychiatric illness were more likely to have increased LOS and non-routine discharge from hospital. In the THA subset, the experimental group had an increased LOS by 1.43 days (p=0.0028), in the TKA subset, the experimental group had an increased LOS by 0.77 days (p= 0.050). In terms of non-routine discharge, the THA experimental group was discharged home 86.9% of the time compared to the control group at 91.8% (p=0.024). In the TKA subset, the experimental group was discharged home 87.6% of the time compared to the control group at 92% (p=0.022). There were no other differences between the two subsets in regards to transfusions, 30-day readmissions, infections, mechanical adverse events, and medical complications. In conclusion, our results demonstrate that psychiatric illness can result in worse outcomes in the early perioperative period after TJA, although outcomes are equivalent 1 year postoperatively. Patients with psychiatric illness can be expected to gain significant improvements in outcome after surgery that are comparable to a baseline population without psychiatric illness. Nonetheless, patients with psychiatric illness are at increased risk of delayed discharge and non-routine discharge. As such, they may require personalized care post-operatively, and should be counseled accordingly. Based on our results, psychiatric illness should not be an impediment to proceeding with TJA

Aims. The purpose of this prospective study was to evaluate the outcomes of coccygectomy for patients with chronic coccydynia. . Patients and Methods. Between 2007 and 2011, 98 patients underwent coccygectomy for chronic coccydynia. The patients were aged > 18 years, had coccygeal pain, local tenderness and a radiological abnormality, and had failed conservative management. Outcome measures were the Short Form 36 (SF-36), the Oswestry Disability Index (ODI) and a visual analogue scale (VAS) for pain. Secondary analysis compared the pre-operative features and the outcomes of patients with successful and failed treatment, two years post-operatively. The threshold for success was based on a minimum clinically important difference (MCID) on the ODI of 20 points. All other patients, including those lost to follow-up, were classified as failures. Results. There was significant improvement in all ten components of the SF-36 (p < 0.05), the ODI (23 points) and VAS (39 points) (p < 0.0001). A total of 69 patients (70.4%) met the designated MCID threshold for a successful outcome. The failure group consisted of 25 patients (25.5%) who did not reach the MCID and four (4.1%) who were lost to follow-up. Six patients (6.1%) in the failure group had ODI scores that were no better or worse than that pre-operatively. The patients in whom treatment failed had significantly worse pre-operative scores for the ODI (p = 0.04), VAS (p = 0.02) and on five of ten SF-36 components (p < 0.04). They also had a higher incidence of psychiatric disorders, pre-operative opiate use and more than three comorbidities. . Take home message: Coccygectomy for chronic coccydynia results in significant improvement in patient-reported outcomes at two years. Failure is associated with certain pre-operative characteristics such as psychiatric illness, poor quality of life features, higher levels of pain, and use of opiates. Cite this article: Bone Joint J 2016;98-B:526–33

Purpose: In children and youth, the prevalence of psychiatric disorder associated with chronic medical illness approximates 30%. The impact of psychiatric disorder on the management of scoliosis has not been well explored in the literature. The objective of this study was to estimate the prevalence of mental health disorders in patients with adolescent idiopathic scoliosis (AIS). Method: Adolescents being treated for AIS completed the Achenbach Youth Self-Report and one parent completed the Achenbach Child Behaviour Checklist. Both measures are validated for screening of mental health disorders. The prevalence of mental health disorder in this population was estimated on the basis of the proportion that screened positive. Univariate analysis and logistic regression analysis was conducted to estimate the association between variables. A sensitivity analysis was performed to estimate the robustness of the results. Results: Between October 2006 and February 2008, 61 of 126 adolescents completed the study (48%). Of the 61 subjects, 18 were treated with observation, 26 with bracing, and 17 with surgical intervention. Overall, there were 41 adolescents who screened positive (67%). Sensitivity analysis demonstrated that, of those who did not return the questionnaire, the prevalence of a positive screen would have had to have been less than 0.1% in order to decrease the overall prevalence to 30%. There was a statistically significant difference in the magnitude of the scoliosis between those who screened positive (mean curve magnitude 39 degrees) compared to those who screened negative (mean curve magnitude 30.6 degrees) (p=0.03). Conclusion: The estimated prevalence of a mental health disorder using the Achenbach questionnaires in patients with AIS is 67%. This is substantially higher than the anticipated prevalence in either the healthy population or those with a chronic illness. The results of this study provide evidence of the high burden of mental health illness amongst those with AIS. The sensitivity analysis demonstrated that the results are robust despite the relatively low response rate

The inmate population is a unique cohort with several healthcare-related challenges. International studies have demonstrated higher rates of infectious diseases, chronic diseases and psychiatric disorders in inmates when compared to general population. However, little is known about the outcomes following total joint arthroplasty in this population. This retrospective chart review aims to outline the differences in clinical outcomes after hip and knee total joint arthroplasty in the Kingston inmate population compared to the national population standard. A list of all inmate inpatient hospital visits with diagnostic/procedure codes pertaining to total joint arthroplasty within the last ten years was obtained through a computer-based search of the Kingston General Hospital Discharge Abstract Database(DAD). The patient charts were reviewed and demographic and outcome data pertinent to our study was collected. Data was compiled using Excel and imported into IBM SPSS for descriptive analysis. Twenty male inmate patients underwent 24 primary Total Hip Arthroplasties(THA) or Total Knee Arthroplasties(TKA) and one medial unicompartmental knee arthroplasty from May 2003 to January 2013. The average age was 58 with mean Body Mass Index(BMI) of 34. Median American Society of Anesthesiologist(ASA) score was 3 and mean Charlston Comorbidity Index was 3.92. The rates of HCV and HIV were 35%(n=5) and 0%, respectively. Average length of stay from time of initial procedure was 4.2 days. The overall revision rate was 24% (n=6). Reasons for revision included deep prosthetic infection (50%, n=3), aseptic loosening (17%, n=1), arthrofibrosis (17%, n=1) and late periprosthetic fracture (17%, n=1). Infection rates were reported at 16% (n=4); 75% of which were deep prosthetic infections requiring revision surgery. Other complications included ST-elevation myocardial infarction(STEMI) (n=1), and postoperative knee stiffness requiring manipulation under anesthesia(MUA) (n=1). Compared to Correctional Services Canada(CSC) data on male inmate health in 2012, our study population demonstrated a higher rate of HCV (35% vs. 9.4%), diabetes (30% vs. 4.2%) and overall cardiovascular and respiratory comorbidities. This may reflect the higher rate of comorbidities associated with osteoarthritis, such as BMI>25, which was evident in 95% of our study population vs. 64.5% in Canadian inmates. Total joint revision rates in our inmate study population was 24%, which is higher than the 2014 Canadian Joint Replacement Registry's yearly revision rate of 8.7% in THA and 5.2% in TKA. Our study population also demonstrated infection as the leading cause for revision at 50%, compared to 14.5% for THA and 19.6% for TKA in the general Canadian population. Further study of the complex biopsychosocial risk factors in the inmate population is warranted to better define pre-surgical risk assessment criteria

Patients with above knee amputation (AKA) often experience poor socket fit exacerbated by minor weight changes, sweating, and skin problems. A transcutaneous, press-fit distal femoral intra-medullary device was designed in 1999, such that the distal external aspect serves as a hard point for AKA prosthesis attachment. The implant is placed in a retrograde fashion, followed 6-8 weeks later by stomatisation and connected via direct extention to an AKA prosthesis. Thirty-seven patients with 39 limbs (30 males, 7 females) underwent two-stage prosthesis implantation with the Endo-Exo Femurprosthesis (EEFP) in Germany between 1999 and January 2008. Their indications for surgery were persistent AKA prosthesis socket difficulties with absence of major comorbid physical or mental illnesses. The patients were followed clinically and radiographically for a minimum of 2 years. Assessments included patient satisfaction ratings, functional surveys, pain scores, and oxygen consumption. Fifty-four percent of patients needed at least one revision (20/37); 80% were minor (16/20) and 20% were major (4/20). Most of the minor revisions were due to soft tissue stomal irritation and occurred prior to a design change in the prosthesis. 2 patients sustained traumatic, peri-trochanteric fractures that were treated operatively proximal to the implant, with retention of the implant. 4 implants were explanted due to infection or prosthesis fracture and 2 of these (50%) were later reimplanted successfully. Overall, 94.9% (37/39) limbs had ultimate EEFP implant success. All functional assessments showed statistically significant improvement over baseline except oxygen consumption, which trended toward improvement. This procedure demonstrated a high degree of functional improvement for the majority of AKA patients treated. Despite an initially high revision rate, the EEFP prosthesis achieves an extremely high rate of successful reconstruction for trans-femoral amputees when more traditional options have failed and therefore warrants further scientific study

The safety and efficacy of bone-healing enhancement with Bone Morphogenetic Protein-7 (BMP) has been studied in the clinical setting of persistent post-traumatic and post-partum pelvic instability. Prospective collection and analysis of all cases with pelvic ring instability after trauma or childbirth, treated with reconstruction and local application of BMP-7. Patient demographics, hospitalisation, operative interventions before and after the BMP-7 grafting, and follow-up data were recorded and evaluated. The median follow-up period was 1 year (range 12 to 18 months). Over a two-year period (March 2005 – January 2007) nine patients (8 females) with median age of 39 years (31–62) were operated for persistent pelvic instability and pain. The mean number of previous operations was 1,6 procedures. Reconstruction of the pelvic ring included 4 cases of post-partum pubic symphysis instability, 2 traumatic non-unions of pubis symphysis and 3 sacroiliatis (1-septic and 2-aseptic). Reconstruction included double plating of pubis symphysis (4-cases), external pelvic fixation (2-cases), sacroiliac screw fixation (1-case) and anterior sacroiliac plating (2-cases). In 4 cases BMP-7 was used alone; in 5 it was used together with iliac crest autograft. All patients were mobilizing with a wheelchair for a period of 8 weeks (6–12) before progressing to full weight bearing. Clinical and radiological union occurred in 8/9 cases at a median time of 14 weeks (range 12–20). One female patient with post-partum pubic symphysis instability and a chronic psychiatric disorder is still complaining of pain despite the radiological evidence of progress of fusion. The rest reported resolution of symptoms. No local or systemic complications or adverse events associated with the use of BMP-7 were recorded. The application of BMP-7 alone or supplementing autografting has been proven to be radiologically 100% and clinically 90% successful and safe following pelvic ring reconstruction as seen in this series of patients

Purpose: To understand the epidemiology and risk factors of an osteoporotic hip fracture in a non-elderly patient. Methods: Retrospective study covering the period 1999–2004, assessing individual and family history, fracture type, hospital stay, time until surgery, type of treatment and possible study or treatment of bone fragility. Results: 38 cases. 23 patients (60.5%) presented some risk factor related to osteoporosis: enolism 7, liver pathology 3, neuromuscular disease 13, steroid treatment 4 and anticonvulsant 3. Seven patients (18.4%) presented some type of psychiatric disorder. Mean hospitalisation time: 13 days. Time until surgery: 3 days. Fracture type: 20 (52.6%) pertrochanteric and 16 (42.10%) subcapital. Treatment: cannulated screws in 11 cases (29%), screw and plate in 21 (55.2%). We found no diagnosis of osteoporosis or related indications in the admission reports except in one patient. Patients over 50: hip fracture incidence 161.21/100,000 inhabitants, pertrochanteric in 54.9% and subcapital in 45.1%. *. . *. A Torrijos, C Ojeda. Area 5 hip study group, La Paz Hospital. Conclusions:. Hip fractures resulting from low-energy trauma are uncommon in the population under the age of 50. There are factors predisposing to bone fragility in 60.5%. The type of fracture is similar to those found in the elderly. Treatment with cannulated screws is more common in non-elderly patients (20% vs 7%*). There is not adequate consideration of the problem of osteoporosis in these patients

The June 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning to identify surgical candidates for hip and knee arthroplasty: a viable option?; Poor outcome after debridement and implant retention; Can you cement polyethylene liners into well-fixed acetabular shells in hip revision?; Revision stem in primary arthroplasties: the Exeter 44/0 125 mm stem; Depression and anxiety: could they be linked to infection?; Does where you live affect your outcomes after hip and knee arthroplasties?; Racial disparities in outcomes after total hip arthroplasty and total knee arthroplasty are substantially mediated by socioeconomic disadvantage both in black and white patients.

The February 2024 Trauma Roundup³⁶⁰ looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years.

Purpose: The double mobility of the G. Bousquet cup—head-polyethylene,polyethylene metal cup—considerably reduces the risk of total hip arthroplasty displacement. Material and methods: We observed seven cases of “intra-prosthetic” displacement in patients with this type of cup. Progressive wear of the polyethylene retention ring allowed displacement of the femoral head. These displacements occurred in six patients (one bilateral case) aged 43–58 years, on the average ten years after the implantation (range 3.5 – 15 years). All patients underwent revision. Results: The polyethylene retention ring was worn in all cases allowing the femoral head to escape. Revision surgery was performed very early in six hips to change the modular base and the polyethylene ring and re-establish retaining capacity. A satisfactory result was achieved in all cases. One patient required revision five years later to change the prosthesis subsequent to haematogenous infection. Another patient underwent a late revision to change the modular base and the entire cup of a press fit implant. This hip was in excellent condition but revision was decided on because of four dislocations. Discussion: Intra-prosthetic displacement of the polyethylene head of a double-mobility cup is exceptional in our experience. Wear of the retention ring is favoured by different elements: 1) direct phenomena: neck and head diameter causing early contact between the neck and the cup; 2) indirect phenomena: factors limiting the mobility of the polyethylene metal cup couple (fibrosis, repeated interventions, ossification). In our experience, intra-prosthetic displacement occurs more readily in patients with favouring conditions (alcoholism, muscle deficiency, psychiatric disorder, obesity) observed in six of our seven cases. Conclusion: Intra-prosthetic displacement of a double-mobility cup is a possible but exceptional complication requiring a technically simple revision. Some teams use this type of cup systematically and for us is an essential element for preventive treatment in high-risk patients and for curative revision of recurrent dislocation

Aims

The aims of this study were to validate the Forgotten Joint Score-12 (FJS-12) in the postoperative evaluation of periacetabular osteotomy (PAO), identify factors associated with joint awareness after PAO, and determine the FJS-12 threshold for patient-acceptable symptom state (PASS).

Aims

The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty.

Aims

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.