Aims. The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients. Methods. Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression. Results. The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times. Conclusion. Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients’ health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment. Cite this article: Bone Joint J 2024;106-B(4):394–400

Aims. The aim of this study was to record the incidence of post-traumatic osteoarthritis (OA), the need for total hip arthroplasty (THA), and patient-reported outcome measures (PROMS) after surgery for a fracture of the acetabulum, in our centre. Patients and Methods. All patients who underwent surgery for an acetabular fracture between 2004 and 2014 were included. Patients completed the 36-Item Short Form Health Survey (SF-36) and the modified Harris Hip Score (mHHS) questionnaires. A retrospective chart and radiographic review was performed on all patients. CT scans were used to assess the classification of the fracture and the quality of reduction. Results. A total of 220 patients were included, of which 55 (25%) developed post-traumatic OA and 33 (15%) underwent THA. A total of 164 patients completed both questionnaires. At a mean follow-up of six years (2 to 10), the mean SF-36 score for patients with a preserved hip joint was higher on role limitations due to physical health problems than for those with OA or those who underwent THA. In the dimension of bodily pain, patients with OA had a significantly better score than those who underwent THA. Patients with a preserved hip joint had a significantly better score on the function scale of the mHHS and a better total score than those with OA or who underwent THA. Conclusion. Of the patients who were treated surgically for an acetabular fracture (with a mean follow-up of six years), 15% underwent THA at a mean of 2.75 years postoperatively. Patients with a THA had a worse functional outcome than those who retain their native hip joint. We recommend using PROMS and CT scans when reviewing these patients. Cite this article: Bone Joint J 2018;100-B:640–5

Objectives. Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property. Methods. A systematic literature search was performed in PubMed, EMbase, CINAHL and PsycINFO databases to identify relevant clinimetric studies. Two reviewers independently assessed the methodological quality of the studies on measurement properties, using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Level of evidence (strong / moderate / limited / lacking) for each measurement property per PROM was determined by combining the methodological quality and the results of the different clinimetric studies. Results. In all, 19 out of 1508 identified unique studies were included, in which 12 PROMs were rated. The Patient-rated wrist evaluation (PRWE) and the Disabilities of Arm, Shoulder and Hand questionnaire (DASH) were evaluated on most measurement properties. The evidence for the PRWE is moderate that its reliability, validity (content and hypothesis testing), and responsiveness are good. The evidence is limited that its internal consistency and cross-cultural validity are good, and its measurement error is acceptable. There is no evidence for its structural and criterion validity. The evidence for the DASH is moderate that its responsiveness is good. The evidence is limited that its reliability and the validity on hypothesis testing are good. There is no evidence for the other measurement properties. Conclusion. According to this systematic review, there is, at best, moderate evidence that the responsiveness of the PRWE and DASH are good, as are the reliability and validity of the PRWE. We recommend these PROMs in clinical studies in patients with distal radial fractures; however, more clinimetric studies of higher methodological quality are needed to adequately determine the other measurement properties. Cite this article: Dr Y. V. Kleinlugtenbelt. Are validated outcome measures used in distal radial fractures truly valid?: A critical assessment using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Bone Joint Res 2016;5:153–161. DOI: 10.1302/2046-3758.54.2000462

Aims. The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. Methods. In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. Results. At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. Conclusion. The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly. Cite this article: Bone Joint J 2023;105-B(1):72–81

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period. Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year. 388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p<0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p<0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276). Of the surgical management group, those that underwent fixation <72 hours post injury were significantly less likely to develop pneumonia than those who were delayed >72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856). Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures

Aims. The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. Methods. We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results. Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion. This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274–282

Aims. Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy. Methods. Adults with an isolated, nonoperatively treated distal radius fracture were included at six weeks post-cast removal. Participants were randomized to delivery of rehabilitation interventions in one of three ways: an advice leaflet; an advice video; or face-to-face therapy session(s). The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at six weeks post intervention and secondary outcome measures included DASH at one year, DASH work subscale, grip strength, and range of motion at six weeks and one year. Results. A total of 116 (97%) of 120 enrolled participants commenced treatment. Of those, 21 were lost to follow-up, resulting in 30 participants in the advice leaflet, 32 in the advice video, and 33 face-to-face therapy arms, respectively at six weeks of follow-up. There was no significant difference between the treatment groups in the DASH at six weeks (advice leaflet vs face-to-face therapy, p = 0.69; advice video vs face-to-face therapy, p = 0.56; advice leaflet vs advice video, p = 0.37; advice leaflet vs advice video vs face-to-face therapy, p = 0.63). At six weeks, there were no differences in any secondary outcome measures except for the DASH work subscale, where face-to-face therapy conferred benefit over advice leaflet (p = 0.01). Conclusion. Following cast removal for nonoperatively treated distal radius fractures, offering an advice leaflet or advice video for rehabilitation gives equivalent patient-reported outcomes to a course of face-to-face therapy. Cite this article: Bone Joint J 2021;103-B(6):1033–1039

Aims. Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years. Methods. Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established. Results. We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery. Conclusion. Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability. Cite this article: Bone Joint J 2024;106-B(1):69–76

Aims. To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture. Methods. A randomized multicentre two-arm parallel-group, participant- and assessor-blinded superiority trial was undertaken. Recruitment commenced on 28 July 2015 and two-year follow-up was completed in 21 October 2019. Participants were 230 adults aged 18 years and over, with acute Achilles tendon rupture managed with non-surgical treatment from 19 UK hospitals. Exclusions were insertion or musculotendinous junction injuries, major leg injury or deformity, diabetes, platelet or haematological disorder, medication with systemic corticosteroids, anticoagulation therapy treatment, and other contraindicating conditions. Participants were randomized via a central online system 1:1 to PRP or placebo injection. The main outcome measure was Achilles Tendon Rupture Score (ATRS) at two years via postal questionnaire. Other outcomes were pain, recovery goal attainment, and quality of life. Analysis was by intention-to-treat. Results. A total of 230 participants were randomized, 114 to PRP and 116 to placebo. Two-year questionnaires were sent to 216 participants who completed a six-month questionnaire. Overall, 182/216 participants (84%) completed the two-year questionnaire. Participants were aged a mean of 46 years (SD 13.0) and 25% were female (57/230). The majority of participants received the allocated intervention (219/229, 96%). Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of a difference in the ATRS at two years (adjusted mean difference -0.752, 95% confidence interval -5.523 to 4.020; p = 0.757) or in other secondary outcomes, and there were no re-ruptures between 24 weeks and two years. Conclusion. PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture. Cite this article: Bone Joint J 2022;104-B(11):1256–1265

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. Methods. This nationwide, retrospective cohort study used data from the Japanese Diagnosis Procedure Combination database. We included older patients (aged ≥ 60 years) who underwent THA or hemiarthroplasty after a femoral neck fracture, between July 2010 and March 2022. A total of 165,123 patients were included. The THA group was younger (mean age 72.6 (SD 8.0) vs 80.7 years (SD 8.1)) and had fewer comorbidities than the hemiarthroplasty group. Patients with dementia or malignancy were excluded because they seldom undergo THA. The primary outcome measures were mortality and complications while in hospital, and secondary outcomes were readmission and reoperation within one and two years after discharge, and the costs of hospitalization. We conducted an instrumental variable analysis (IVA) using differential distance as a variable. Results. The IVA analysis showed that the THA group had a significantly higher rate of complications while in hospital (risk difference 6.3% (95% CI 2.0 to 10.6); p = 0.004) than the hemiarthroplasty group, but there was no significant difference in the rate of mortality while in hospital (risk difference 0.3% (95% CI -1.7 to 2.2); p = 0.774). There was no significant difference in the rate of readmission (within one year: risk difference 1.3% (95% CI -1.9 to 4.5); p = 0.443; within two years: risk difference 0.1% (95% CI -3.2 to 3.4); p = 0.950) and reoperation (within one year: risk difference 0.3% (95% CI -0.6 to 1.1); p = 0.557; within two years: risk difference 0.1% (95% CI -0.4 to 0.7); p = 0.632) after discharge. The costs of hospitalization were significantly higher in the THA group than in the hemiarthroplasty group (difference $2,634 (95% CI $2,496 to $2,772); p < 0.001). Conclusion. Among older patients undergoing surgery for a femoral neck fracture, the risk of early complications was higher after THA than after hemiarthroplasty. Our findings should aid in clinical decision-making in these patients. Cite this article: Bone Joint J 2024;106-B(9):986–993

Aims. There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. Methods. A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. Results. Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges’ g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. Conclusion. We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953–962

The objectives of our study were to compare patient reported outcome measures between manual and robotic-assisted total hip arthroplasty. Between 1st May 2021 and 31st August 2022, 539 consecutive patients who underwent 564 primary total hip arthroplasties were identified from the local registry database. Data were prospectively collected, and included patient demographics, American Society of Anaesthesiologists (ASA) grade, surgical approach, robotic-assistance, Oxford Hip Score (OHS), EQ-5D-3L and EQ-VAS pre-operatively and at twelve months. Robotic-assistance, compared against manual total hip arthroplasty, was associated with an enhanced median (interquartile range) OHS (46 [42 – 48] vs 43 [36 – 47], p-value < 0.001), EQ-5D-3L (5 [5 – 7] vs 6 [5 – 8], p-value 0.002), and EQVAS (90 [75 – 95] vs 80 [70 – 90], p-value 0.003) at twelve months after surgery. Robotic-assistance was confirmed to be an independent predictor of a greater OHS at twelve months on a multivariate linear regression analysis (p-value 0.001). Robotic assistance was superior to manual total hip arthroplasty in enhancing patient reported outcomes at twelve months after surgery

The aims of this study in relation to distal radius fractures were to determine (1) the floor and ceiling effects for the QuickDASH and PRWE, (2) the floor and ceiling effects when defined to be within the minimal clinically important difference (MCID) of the minimal or maximal scores, (3) the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and (4) patent factors associated with a floor or ceiling effect. A retrospective cohort study of patients sustaining a distal radius fracture during a single year was undertaken. Outcome measures included the QuickDASH, PRWE, EQ-5D-3L and normal wrist score. There were 526 patients with a mean age of 65yrs and 77% were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs. A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the MCID of the best score, the effect increased to 62.8% for the QuickDASH and 60% for PRWE. Patients that achieved the best functional outcome according to the QuickDASH and PRWE felt their wrist was only 91% and 92% normal, respectively. Sex (p=0.000), age (p=0.000), dominant wrist injury (p=0.006 for QuickDASH and p=0.038 for PRWE), fracture type (p=0.015), and a better health-related quality of life (p=0.000) were independently associated with achieving a ceiling score. The QuickDASH and PRWE demonstrated ceiling effects following a distal radius fracture. Patients achieving ceiling scores did not consider their wrist to be ‘normal’ for them

Introduction. Chronic ankle instability is a common condition that can be effectively treated with arthroscopic lateral ankle ligament reconstruction to restore ankle stability and function. The aim of this study was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the MOXFQ, VAS, and EQ5D patient-reported outcome measures (PROMs). Methods. This prospective series included 38 patients who underwent arthroscopic lateral ligament reconstruction for chronic ankle instability between December 2019 and April 2022. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, as well as at6, and 12 months postoperatively. The MOXFQ is a disease-specific PROM that assesses foot and ankle function, while the VAS measures pain and the EQ5D evaluates health-related quality of life. Results. At the 12-month follow-up, the mean MOXFQ Index score had improved significantly from 53.3 ± 23.1 preoperatively to 16.0 ±21.1 (p < 0.001). Similarly, the mean VAS score had improved from 36.2 ± 22.4 preoperatively to 14.7 ± 15.0 (p < 0.001), and the meanEQ5D score had improved from 0.55 ± 0.26 preoperatively to 0.87 ± 0.12 (p < 0.001). No major complications were observed. Conclusion. Arthroscopic lateral ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the most reliable surgical option, for hallux rigidus from end-stage osteoarthritis. The aim of the study was to compare the functional outcomes of memory nickel-titanium staples versus a compression plate with a cross screw construct for first MTPJ arthrodesis using the Manchester–Oxford Foot Questionnaire (MOXFQ). Patients who underwent MTPJ arthrodesis using either memory nickel-titanium staples or a compression plate with a cross screw construct were identified from the surgical lists of two orthopaedic consultants. Pre and post-operative MOXFQ questionnaire, a validated patient-reported outcome measure, was administered, and responses were analysed to derive the MOXFQ summary index. The study included 38 patients (staple group N=12 and plate and cross screw group N=26). 23 patients were female and 15 were male. Mean age was 64.8 years (SD 9.02; 40 to 82). Initial analysis showed no significant difference in preoperative MOXFQ scores between the groups (p = 0.04). Postoperatively, the staple group exhibited a mean improvement of 36.17, surpassing the plate group's mean improvement of 23. Paired t-test analysis revealed a statistically significant difference (t-score= 2.5, p = 0.008), favouring the use of staples. The findings indicate that the use of staples in MTPJ arthrodesis resulted in a significantly greater improvement in MOXFQ scores compared to plates. Further research is needed to explore the underlying factors contributing to this difference and to evaluate long-term effects on patient outcomes

Multiligament knee injuries (MLKI) are associated with significant morbidity and healthcare requirements. The primary aim of this study is to report the patient reported outcomes measures (PROMs) after reconstructive surgery. Patients undergoing surgery for MLKI between 2014 and 2018 in the single large-volume trauma centre were included. Electronic patient records were reviewed for demographic data, details of surgery and complications. PROMs collected were EQ-5D-5L, Lysholm Knee Score (LKS), UCLA Activity and Sport and patient satisfaction. Thirty-five patients were included. Mean age was 31 years (range 16-66), and 71% were male. The most common mechanism of injury was sports-related (71%). Obesity was present in eight (23%) patients. No vascular injuries were recorded and four patients sustained nerve injuries. PROMs were available for 18 patients (51%) with a median follow up of 4.5 years. Median EQ-5D-5L was 0.78 (IQR 0.14). Median LKS was 84.5 (IQR 21) and there was no correlation with time to surgery (p=0.43). Grade of MLKI did not impact LKS (p=0.09). Fifteen patients (83%) saw a reduction in their activity level. All patients were satisfied with their surgical treatment. Recurrent instability was noted in four patients (11%). Three patients (8%) required further surgery (one revision reconstruction, one meniscectomy, one conversion to a hinged knee replacement. This study demonstrates two groups of patients who sustain MLKI: the sporting population and obese patients. Health related quality of life, functional outcomes and satisfaction are high after surgery. Time to surgery did not impact on functional outcomes

This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture. 70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL). At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups. Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr

Aim of this study was to identify reoperation rates in patients with short oblique and transverse fractures around a well fixed cemented polished taper slip stem and to determine any associations with treatment failure. Retrospective cohort study of 31 patients with AO transverse or short oblique Vancouver B1 PFFs around THA (total hip arthroplasty) cemented taper slip stems: 12 male (39%); mean age 74±11.9 (range 44–91); mean BMI 28.5±1.4 (range 16–48); and median ASA 3. Patient journeys were assessed, re-interventions reviewed. The primary outcome measure was reoperation. Time from primary THA to fracture was 11.3±7.8yrs (0.5–26yrs). Primary surgical management was fixation in 27/31 and rTHA (revision total hip arthroplasty) in 4/31. 10 of 31 (32%) patients required reoperation, 9 within 2 years of fracture: 1 following rTHA and 8 following ORIF. The commonest mode of failure was non-union (n=6). No significant associations with reoperation requirement were identified. Kaplan-Meier free from reoperation was 67.4% (49.8–85.0 95% CI) at 2 years and this was unaffected by initial management with ORIF or rTHA (Log rank 0.898). Of those reoperated, 6/10 required multiple reoperations to obtain either bony union or a stable revision construct and 13% ultimately required proximal femoral endoprostheses. The relative risk of 1 year mortality was 1.6 (0.25 to 10.1 95%CI) among patients who required reoperation compared to those who did not. These are difficult fractures to manage, should not be underestimated and patients should be counselled that there is a 30% risk of reoperation and 20% of requiring multiple reoperations

Hip fracture patients are vulnerable to delirium. This study examined the associations between delirium and outcomes including mortality, length of stay, post-discharge care requirements, and readmission. This cohort study collected validated healthcare data for all hip fracture patients aged ≥50 years that presented to a high-volume centre between March 2020-November 2021. Variables included: demographics, delirium status, COVID-19 status, treatment factors, and outcome measures. Wilcoxon rank sum or Chi-squared tests were used for baseline differences, Cox proportional hazard regression for mortality, logistic regression for post-discharge care requirements and readmission, and linear regression for length of stay. Analyses were adjusted for age, sex, deprivation, pre-fracture residence type and COVID-19. There were 1822 patients (mean age 81 years; 72% female) of which 496/1822 (27.2%) had delirium (4AT score ≥4). Of 371/1822 (20.4%) patients that died within 180 days of admission, 177/371 (47.7%) had delirium during the acute stay. Delirium was associated with an increased 30- and 180-day mortality risk (adjusted HR 1.74 (95%CI 1.15-2.64; p=0.009 and 1.74 (1.36-2.22; p<0.001), respectively), ten day longer total inpatient stay [adj. B.coef 9.80 (standard error 2.26); p<0.001] and three-fold greater odds of higher care requirements on discharge [Odds Ratio 3.07 (95% Confidence Interval 2.27-4.15; p<0.001)]. More than a quarter of patients had delirium during the hip fracture stay, and this was independently associated with increased mortality, longer length of stay, and higher post-discharge care requirements. These findings are relevant for prognostication and service planning, and emphasise the importance of effective delirium screening and evidence-based interventions in this vulnerable population

Aims. There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results. A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion. MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients. Cite this article: Bone Joint J 2024;106-B(4):387–393