Aims. The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population. Methods. This is a multicentre retrospective cohort study including adult patients presenting to hospital with a new PPF between 1 January 2018 and 31 December 2018. Data collected included: patient characteristics, comorbidities, anticoagulant use, social circumstances, level of mobility, fracture characteristics, Unified Classification System (UCS) type, and details of the original implant. Descriptive analysis by fracture location was performed, and predictors of PPF type were assessed using mixed-effects logistic regression models. Results. In total, 720 femoral PPFs from 27 NHS sites were included. PPF patients were typically elderly (mean 79.9 years (SD 10.6)), female (n = 455; 63.2%), had at least one comorbidity (n = 670; 93.1%), and were reliant on walking aids or bed-/chair-bound prior to admission (n = 419; 61.7%). The study population included 539 (74.9%) hip PPFs, 151 (21.0%) knee PPFs, and 30 (4.2%) dividing type PPFs. For hip (n = 407; 75.5%) and knee (n = 88; 58.3%) arthroplasty UCS B type fractures were most common. Overall, 556 (86.2%) were treated in the presenting hospital and 89 (13.8%) required transfer for treatment. Female sex was the only significant predictor of fracture type (A/B1/C type versus B2/B3) for femoral hip PPFs (odds ratio 0.61 (95% confidence interval 0.41 to 0.91); p = 0.014). Sex, residence type, primary versus revision implant PPF, implant fixation, and time between arthroplasty and PPF were not found to predict fracture type for hip PPFs. Conclusion. This multicentre analysis describes patient and injury factors for patients presenting with femoral PPFs to centres across the UK. These patients are generally elderly and frail, comparable to those sustaining a hip fracture. These data can be useful in planning future services and clinical trials. Cite this article: Bone Joint J 2022;104-B(8):987–996

Aims. This study explores the epidemiology of patients with a fracture of the scaphoid presenting to a regional teaching hospital. Patients and Methods. All patients with a confirmed fracture of the scaphoid over a retrospective period between January 2010 and May 2013 were included. Their demographics, deprivation status and when the fracture occurred was noted and assessed. There were 415 fractures in 365 males and 50 females. Results. The incidence of fracture of the scaphoid was 12.4 in 100 000 each year in the general population. The mean age of the patients was 22 years (nine to 35); the highest incidence was in males aged between 15 and 19 years. We calculate the annual incidence in the United Kingdom to be 7265 each year. Patients with the lowest socioeconomic status had an incidence of 18.57 in 100 000 whereas the least deprived patients had an incidence of 9.98 (p < 0.001). There was evidence of a seasonal trend (p = 0.022) with the highest monthly rate found in June (16.96 in 100 000 each year) and the lowest was in December (7.61 in 100 000 each year). There were significantly fewer presentations of fracture at the weekend (p <  0.001), and the highest incidence was on Mondays. Most fractures occurred at the waist (64%) and tubercle (18.1%). Take home message: In this large-scale epidemiological study, we confirmed that young men are most at risk of sustaining a fracture of the scaphoid, and report new factors in relation to social deprivation and seasonality that influence scaphoid fractures. Cite this article: Bone Joint J 2016;98-B:654–9

Aims. The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip. Methods. This was an anonymized comprehensive cohort study of Perthes’ disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children’s hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. Overall, 371 children (396 hips) were newly affected by Perthes’ disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years. Conclusion. Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510–518

Aims. This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries. Patients and Methods. In England, the Hospital Episode Statistics (HES) data are recorded annually. Between 2000/01 and 2016/17, the number of adults admitted to an English NHS hospital with a calcaneal fracture and whether they underwent surgical treatment was determined. Results. During this 17-year period, 62 858 patients were admitted to hospital with a calcaneal fracture. The male-to-female ratio was 2.66:1. The mean annual incidence was 10.5/100 000 for men and 3.8/100 000 for women. The results of the UK HeFT were published in July 2014. The percentage of patients admitted with a calcaneal fracture undergoing internal fixation was 7.31% (3792/51 859) before and 7.38% (534/7229) after its publication. This difference was not statistically significant (p = 0.94). Since 2015, there has been a significant increase in the percentage of calcaneal fractures treated by closed reduction and internal fixation, as opposed to open reduction and internal fixation, from 7.7% (292/3792) to 13.29% (71/534) (p < 0.001). Conclusion. This study documents the epidemiology and trends in surgical treatment of calcaneal fractures in England. We established that surgeons did not change their practice in terms of offering surgery to these patients in response to the results of the UK HeFT. There has been a significant (p < 0.001) increase in the number of calcaneal fractures being treated surgically using less invasive procedures

Aims. The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB. Methods. A total of 284 patients with clinically and radiologically suspected infectious spondylodiscitis were prospectively recruited into the study. Image-guided biopsy of the vertebral lesion was performed and specimens were sent for various microbiological tests and histological examinations. The final diagnosis was determined using a composite reference standard based on clinical, radiological, serological, microbiological, and histological findings. The overall diagnostic yield of the biopsy, and that for each test, was calculated in light of the final diagnosis. Results. The final diagnosis was tuberculous spondylodiscitis in 250 patients (88%) and pyogenic spondylodiscitis in 22 (7.8%). Six (2.1%) had a noninfectious condition-mimicking infectious spondylodiscitis, and six (2.1%) had no definite diagnosis and improved without specific treatment. The diagnosis was made by image-guided biopsy in 152 patients (56%) with infectious spondylodiscitis. Biopsy was contributory in identifying 132/250 patients (53%) with tuberculous spondylodiscitis, and 20/22 patients (91%) with pyogenic spondylodiscitis. Histological examination was the most sensitive diagnostic modality, followed by Xpert MTB/RIF assay. Conclusion. Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. A combination of histological examination, Xpert MTB/RIF assay, bacterial culture, and sensitivity provides high diagnostic accuracy in a country in which TB is endemic. Cite this article: Bone Joint J 2022;104-B(1):120–126

Total knee arthroplasty (TKA) is a cost effective and extremely successful operation. As longevity increases, the demand for primary TKA will continue to rise. The success and survivorship of TKAs are dependent on the demographics of the patient, surgical technique and implant-related factors. . Currently the risk of failure of a TKA requiring revision surgery ten years post-operatively is 5%. . The most common indications for revision include aseptic loosening (29.8%), infection (14.8%), and pain (9.5%). Revision surgery poses considerable clinical burdens on patients and financial burdens on healthcare systems. . We present a current concepts review on the epidemiology of failed TKAs using data from worldwide National Joint Registries. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):105–12

Aims. This study aimed to describe the use of revision knee arthroplasty in Australia and examine changes in lifetime risk over a decade. Methods. De-identified individual-level data on all revision knee arthroplasties performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data and life tables were obtained from the Australian Bureau of Statistics. The lifetime risk of revision surgery was calculated for each year using a standardized formula. Separate calculations were undertaken for males and females. Results. In total, 43,188 revision knee arthroplasty procedures were performed in Australia during the study period, with a median age at surgery of 69 years (interquartile range (IQR) 62 to 76). In 2017, revision knee arthroplasty rates were highest for males aged 70 to 79 years (102.9 procedures per 100,000 population). Lifetime risk of revision knee arthroplasty for females increased slightly from 1.61% (95% confidence interval (CI) 1.53% to 1.69%) in 2007 to 2.22% (95% CI 2.13% to 2.31%) in 2017. A similar pattern was evident for males, with a lifetime risk of 1.43% (95% CI 1.36% to 1.51%) in 2007 and 2.02% (95% CI 1.93% to 2.11%) in 2017. A decline in procedures performed for loosening/lysis (from 41% in 2007 to 24% in 2017) and pain (from 14% to 9%) was evident, while infection became an increasingly common indication (from 19% in 2007 to 29% in 2017). Conclusion. Well-validated national registry data can help us understand the epidemiology of revision knee arthroplasty, including changing clinical indications. Despite a small increase over a decade, the lifetime risk of revision knee arthroplasty in Australia is low at one in 45 females and one in 50 males. These methods offer a population-level approach to quantifying revision burden that can be used for ongoing national surveillance and between-country comparisons. Cite this article: Bone Joint J 2022;104-B(5):613–619

We investigated the epidemiology, assessment and outcome of acute atraumatic limp in 243 children under the age of 14 years presenting to a paediatric accident and emergency department (AED) over a period of six months. Data were collected at presentation and medical notes were re-examined after 18 to 21 months. The incidence of limp was 1.8 per thousand. The male:female ratio was 1.7:1 and the median age 4.35 years. Limp was mainly right-sided (54%) and painful (80%); 33.7% of the children had localised pain in the hip. A preceding illness was found in 40%. The main diagnosis was ‘irritable hip’/transient synovitis (39.5%); Perthes’ disease accounted for 2%. Most patients (77%) were managed entirely in the AED. Acute atraumatic limp is a common problem in children presenting to the AED. Most can be safely managed there if guidelines are followed and will have a benign outcome. Further studies are needed to identify the role of preceding illness in the aetiology of acute atraumatic limp

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered

We have attempted to describe the epidemiology of femoral fractures in children in the West Midlands region of the National Health Service in England. Our source of data was the Regional Hospital Episode Statistics database for the years 1991-2 to 2001-2. Cases were defined as emergency hospital admissions in patients aged under 16 years, with a diagnostic code of femoral fractures in any field, and resident in the West Midlands. Between 1991-2 and 2001-2, 3272 children aged under 16 years with femoral fractures were admitted to hospital. The crude incidence during this period decreased from 0.33 to 0.22 femoral fractures/1000/year. Those caused by traffic accidents decreased by 43%, and by falls by 29%. The peak age-gender-specific incidence (0.91/1000/year) was in two-year-old boys, and this was 50% higher than in the next highest age-gender group. In the first year of life, the incidence in boys and girls was the same. Thereafter the rate in boys exceeded that in girls, varying from 1.6 times at 11 years to 4.7 times at 14 years. Falls accounted for 49% of the fractures, varying from 77% in one-year-olds to 26% in eight-year-old children. Traffic accidents were responsible for 26% of fractures varying from 55% in ten-year-old to 2% in one-year-old children. Maltreatment was recorded in 1.3% of all cases, and in 8.5% of children under one year. Twice as many fractures were seen in May to August than in January (winter). The rates of fractures were associated with deprivation for all age-gender groups. Fractures of the shaft accounted for 58% of all fractures, varying from 70% in three-year-old to 34% in 13-year-old children. Our findings show that there has been a decrease in the incidence of femoral fractures during the 1990s and early 2000s. Two-year-old boys had twice the rate than any other single-year age-gender group. More deprived areas had much higher rates which suggests the potential for greater prevention. A relatively low rate of maltreatment was recorded compared with that in some other studies

Aims

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.

Aims

The goals of this study were to define the risk factors, characteristics, and chronology of fractures in 5417 revision total hip arthroplasties (THAs).

A relationship between social deprivation and the incidence of fracture in adolescents has not previously been shown. We have used a complete fracture database to identify adolescents who sustained fractures in 2000. The 2001 Scottish census was used to obtain age-specific population and deprivation data according to the Carstairs score. Regression analysis determined the relationship between the incidence of fractures and social deprivation.

We analysed 1574 adolescents with fractures (1083 male, 491 female). The incidence of fractures in this group was 21.8 per thousand (31.0 male, 13.1 female). Social deprivation predicted the incidence in adolescent males and females. The incidence of fractures of the proximal upper limb and distal radius in females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20 years of age were more likely to sustain fractures of the hand and carpus if they lived in economically depressed neighbourhoods.

Aim and Methods

The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs).

We performed an epidemiological analysis of 523 fractures treated in the Edinburgh Orthopaedic Trauma Unit over a three-year period using modern descriptive criteria. The fractures were defined in terms of their AO morphology and their degree of comminution, location and cause. Closed fractures were classified using the Tscherne grading system and open fractures according to the Gustilo classification. Further analysis of fractures caused by road-traffic accidents and football was carried out. The use of the AO classification allowed the common fracture patterns to be defined. Correlation of the classification systems showed an association between the AO morphological system and the Tscherne and Gustilo classifications. The relative rarity of severe tibial fractures is indicated and it is suggested that in smaller orthopaedic units the infrequency of these fractures has implications for training and the development of treatment protocols.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are recognised and proven interventions for patients with advanced arthritis. Studies to date have demonstrated a steady increase in the requirement for primary and revision procedures. Projected estimates made for the United States show that by 2030 the demand for primary TKA will grow by 673% and for revision TKA by 601% from the level in 2005. For THA the projected estimates are 174% and 137% for primary and revision surgery, respectively. The purpose of this study was to see if those predictions were similar for England and Wales using data from the National Joint Registry and the Office of National Statistics.

Analysis of data for England and Wales suggest that by 2030, the volume of primary and revision TKAs will have increased by 117% and 332%, respectively between 2012 and 2030. The data for the United States translates to a 306% cumulative rate of increase between 2012 and 2030 for revision surgery, which is similar to our predictions for England and Wales.

The predictions from the United States for primary TKA were similar to our upper limit projections. For THA, we predicted an increase of 134% and 31% for primary and revision hip surgery, respectively.

Our model has limitations, however, it highlights the economic burden of arthroplasty in the future in England and Wales as a real and unaddressed problem. This will have significant implications for the provision of health care and the management of orthopaedic services in the future.

Cite this article: Bone Joint J 2015;97-B:1076–1081.

We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system.

The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.

We examined prospectively collected data from 6782 consecutive hip fractures and identified 327 fractures in 315 women aged ≤65 years. We report on their demographic characteristics, treatment and outcome and compare them with a cohort of 4810 hip fractures in 4542 women aged > 65 years.

The first significant increase in age-related incidence of hip fracture was at 45, rather than 50, which is when screening by the osteoporosis service starts in most health areas. Hip fractures in younger women are sustained by a population at risk as a result of underlying disease. Mortality of younger women with hip fracture was 46 times the background mortality of the female population. Smoking had a strong influence on the relative risk of ‘early’ (≤ 65 years of age) fracture.

Lag screw fixation was the most common method of operative treatment. General complication rates were low, as were re-operation rates for cemented prostheses. Kaplan-Meier implant survivorship of displaced intracapsular fractures treated by reduction and lag screw fixation was 71% (95% confidence interval 56 to 81) at five years. The best form of treatment remains controversial.

We reviewed 275 cases and calculated the prevalence of bacteriologically or radiologically confirmed acute haematogenous osteomyelitis in children under 13 resident in Greater Glasgow during 1970 to 1990. In the 20-year period there was a fall of over 50%, mainly involving cases of long-bone infection, and those due to Staphylococcus aureus. There was a reduced incidence of complications. The proportion of cases involving long bones decreased from 84% to 57%, and those of Staphylococcus aureus infection from 55% to 31%. These changes, in what is becoming a rare disease, need to be known to ensure early diagnosis and adequate treatment, particularly of subacute non-staphylococcal infection at unusual sites.

A nationwide study of Perthes’ disease in Norway was undertaken over a five-year period from January 1996. There were 425 patients registered, which represents a mean annual incidence of 9.2 per 100 000 in subjects under 15 years of age, and an occurrence rate of 1:714 for the country as a whole. There were marked regional variations. The lowest incidence was found in the northern region (5.4 per 100 000 per year) and the highest in the central and western regions (10.8 and 11.3 per 100 000 per year, respectively). There was a trend towards a higher incidence in urban (9.5 per 100 000 per year) compared with rural areas (8.9 per 100 000 per year). The mean age at onset was 5.8 years (1.3 to 15.2) and the male:female ratio was 3.3:1.

We compared 402 patients with a matched control group of non-affected children (n = 1 025 952) from the Norwegian Medical Birth Registry and analysed maternal data (age at delivery, parity, duration of pregnancy), birth length and weight, birth presentation, head circumference, ponderal index and the presence of congenital anomalies. Children with Perthes’ disease were significantly shorter at birth and had an increased frequency of congenital anomalies.

Applying Sartwell’s log-normal model of incubation periods to the distribution of age at onset of Perthes’ disease showed a good fit to the log-normal curve. Our findings point toward a single cause, either genetic or environmental, acting prenatally in the aetiology of Perthes’ disease.

We report a prospective study of the incidence of fractures in the adult population of Edinburgh, related to age and gender. Over a two-year period, 15 293 adults, 7428 males and 7865 females, sustained a fracture, and 5208 (34.0%) required admission.

Between 15 and 49 years of age, males were 2.9 times more likely to sustain a fracture than females (95% CI 2.7 to 3.1). Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4). There were three main peaks of fracture distribution: the first was in young adult males, the second was in elderly patients of both genders, mainly in metaphyseal bone such as the proximal femur, although diaphyseal fractures also showed an increase in incidence. The third increase in the incidence of fractures, especially of the wrist, was seen to start at 40 years of age in women.

Our study has also shown that ‘osteoporotic’ fractures became evident in women earlier than expected, and that they were not entirely a postmenopausal phenomenon.

We have reviewed the incidence of bacteriologically or radiologically confirmed acute haematogenous osteomyelitis in children under 13 years of age resident in the area of the Greater Glasgow Health Board between 1990 and 1997. In this period there was a fall of 44% in the incidence of both acute and subacute osteomyelitis, mainly involving the acute form (p = 0.005). This mirrors the decline of just over 50% previously reported in the same population between 1970 and 1990. Using multiple regression analysis a decline in incidence of 0.185 cases per 100 000 population per year was calculated for the 28-year period (p > 0.001).

Staphylococcus was the most commonly isolated pathogen (70%). Only 20% of patients required surgery and there was a low rate of complications (10%). In general, patients with a subacute presentation followed a benign course and there were no complications or long-term sequelae in this group.

Haematogenous osteomyelitis in children in this area is becoming a rare disease with an annual incidence of 2.9 new cases per 100 000 population per year.

The prevalence and onset of pressure sores was studied in 283 patients admitted to a general hospital with either fracture of the proximal femur or for elective hip surgery. Ninety patients developed pressure sores, of which 60 are reported in detail. Most were in women aged 70 or more who had been admitted with hip fractures. The majority of pressure sores started soon after admission, particularly on the day of operation, after which the numbers of new cases decreased. Half the patients had more than one pressure sore and the commonest sites were the sacrum, heels, and buttocks. The mortality in patients with pressure sores was 27% and their mean length of stay in hospital far exceeded that of other patients. The prevention of pressure sores in elderly patients requires more skill and attention than the nurse alone can offer; it demands the help of the whole orthopaedic team.

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Cite this article: Bone Joint J 2015; 97-B:442–8.

From 1981 to 1986 we treated 413 patients for acute spinal-cord injuries. We reviewed 356 patients followed for a minimum of two years of whom 71 (20%) developed heterotopic ossification around one or more joints. Heterotopic ossification occurred more often in male patients (23%) than in female (10%), and was most frequent in the 20- to 30-year age group. It was also more common after injuries of the lower cervical or thoracic spine than after those of the lumbar spine. Patients with severe neurological deficits (Frankel grades A and B) showed significantly more heterotopic ossification but there was no correlation with the number or severity of associated head and limb injuries. Serum calcium levels did not change significantly in either group for 30 weeks after injury, but the erythrocyte sedimentation rate and the alkaline phosphatase level were significantly increased at six weeks in patients with heterotopic ossification.

In a prospective five-year study, 294 episodes of acute transient synovitis of the hip were diagnosed in 275 children. The average annual incidence was 0.2% and the accumulated risk of suffering at least one episode was 3%. The risk of recurrence was 20 times greater than the risk of having a single episode. Perthes' disease was diagnosed from one to five months after the acute attack of synovitis in 10 cases (3.4%). Review of the initial radiographs revealed signs of avascular necrosis in three of the 10 cases, and an increased joint space in five. Only two cases had had completely normal radiographs. The value of routine radiographs taken after three months was minimal. Factors associated with the incidence of Perthes' disease included prolonged time in traction before the range of hip movement became normal, increase in joint space on the initial radiographs and the recurrence of hip symptoms after initial relief.

Aims. The aim of this study was to identify factors associated with five-year cancer-related mortality in patients with limb and trunk soft-tissue sarcoma (STS) and develop and validate machine learning algorithms in order to predict five-year cancer-related mortality in these patients. Methods. Demographic, clinicopathological, and treatment variables of limb and trunk STS patients in the Surveillance, Epidemiology, and End Results Program (SEER) database from 2004 to 2017 were analyzed. Multivariable logistic regression was used to determine factors significantly associated with five-year cancer-related mortality. Various machine learning models were developed and compared using area under the curve (AUC), calibration, and decision curve analysis. The model that performed best on the SEER testing data was further assessed to determine the variables most important in its predictive capacity. This model was externally validated using our institutional dataset. Results. A total of 13,646 patients with STS from the SEER database were included, of whom 35.9% experienced five-year cancer-related mortality. The random forest model performed the best overall and identified tumour size as the most important variable when predicting mortality in patients with STS, followed by M stage, histological subtype, age, and surgical excision. Each variable was significant in logistic regression. External validation yielded an AUC of 0.752. Conclusion. This study identified clinically important variables associated with five-year cancer-related mortality in patients with limb and trunk STS, and developed a predictive model that demonstrated good accuracy and predictability. Orthopaedic oncologists may use these findings to further risk-stratify their patients and recommend an optimal course of treatment. Cite this article: Bone Joint J 2023;105-B(6):702–710

Aims. The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis. Methods. Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed. Results. A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001). Conclusion. This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483

Aims. The management of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is challenging. The correct antibiotic management remains elusive due to differences in epidemiology and resistance between countries, and reports in the literature. Before the efficacy of surgical treatment is investigated, it is crucial to analyze the bacterial strains causing PJI, especially for patients in whom no organisms are grown. Methods. A review of all revision TKAs which were undertaken between 2006 and 2018 in a tertiary referral centre was performed, including all those meeting the consensus criteria for PJI, in which organisms were identified. Using a cluster analysis, three chronological time periods were created. We then evaluated the antibiotic resistance of the identified bacteria between these three clusters and the effectiveness of our antibiotic regime. Results. We identified 129 PJIs with 161 culture identified bacteria in 97 patients. Coagulase-negative staphylococci (CNS) were identified in 46.6% cultures, followed by Staphylococcus aureus in 19.8%. The overall resistance to antibiotics did not increase significantly during the study period (p = 0.454). However, CNS resistance to teicoplanin (p < 0.001), fosfomycin (p = 0.016), and tetracycline (p = 0.014) increased significantly. Vancomycin had an 84.4% overall sensitivity and 100% CNS sensitivity and was the most effective agent. Conclusion. Although we were unable to show an overall increase in antibiotic resistance in organisms that cause PJI after TKA during the study period, this was not true for CNS. It is concerning that resistance of CNS to new antibiotics, but not vancomycin, has increased in a little more than a decade. Our findings suggest that referral centres should continuously monitor their bacteriological analyses, as these have significant implications for prophylactic treatment in both primary arthroplasty and revision arthroplasty for PJI. Cite this article: Bone Joint J 2021;103-B(6 Supple A):171–176

Aims. The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures. Methods. A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. Results. Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; p < 0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: 1) age, sex, type of residence (hazard ratio (HR) 2.93; p = 0.008); 2) Nottingham Hip Fracture Score (HR 3.52; p = 0.001); and 3) ASA (HR 3.45; p = 0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of < 217 × 10. 9. /l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. Conclusion. COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219–1228

Aims. The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). Methods. This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define ‘at risk’. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE. Conclusion. The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519–528

Aims. The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting. Methods. A total of 421 patients from the Cohort Hip and Cohort Knee (CHECK) database, a population-based observational cohort, with hip and knee complaints < 6 months, aged between 45 and 65 years old, and with lateral lumbar, hip, and knee radiographs available, were included. Sagittal spinopelvic parameters and pathologies (spondylolisthesis and degenerative disc disease (DDD)) were measured at eight-year follow-up and characteristics of hip and knee osteoarthritis (OA) at baseline and eight-year follow-up. Epidemiology of the degenerative disorders and clinical outcome scores (hip and knee pain and Western Ontario and McMaster Universities Osteoarthritis Index) were compared between low PI (< 50°), normal PI (50° to 60°), and high PI (> 60°) using generalized estimating equations. Results. Demographic details were not different between the different PI groups. L4 to L5 and L5 to S1 spondylolisthesis were more frequently present in subjects with high PI compared to low PI (L4 to L5, OR 3.717; p = 0.024 vs L5 to S1 OR 7.751; p = 0.001). L5 to S1 DDD occurred more in patients with low PI compared to high PI (OR 1.889; p = 0.010), whereas there were no differences in L4 to L5 DDD among individuals with a different PI. The incidence of hip OA was higher in participants with low PI compared to normal (OR 1.262; p = 0.414) or high PI (OR 1.337; p = 0.274), but not statistically different. The incidence of knee OA was higher in individuals with a high PI compared to low PI (OR 1.620; p = 0.034). Conclusion. High PI is a risk factor for development of spondylolisthesis and knee OA. Low pelvic incidence is related to DDD, and may be linked to OA of the hip. Level of Evidence: 1b. Cite this article: Bone Joint J 2020;102-B(9):1261–1267

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: Bone Joint J 2020;102-B(5):556–567

Tuberculosis (TB) remains endemic in many parts of the developing world and is increasingly seen in the developed world due to migration. A total of 1.3 million people die annually from the disease. Spinal TB is the most common musculoskeletal manifestation, affecting about 1 to 2% of all cases of TB. The coexistence of HIV, which is endemic in some regions, adds to the burden and the complexity of management. This review discusses the epidemiology, clinical presentation, diagnosis, impact of HIV and both the medical and surgical options in the management of spinal TB. Cite this article: Bone Joint J 2018;100-B:425–31

Aims. The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. Patients and Methods. National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. Results. A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). . Conclusion. This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109–18

Aims. The aims of the study were to review and analyse the reported series of debridement, antibiotics and implant retention (DAIR) in the management of infected total hip arthroplasties (THAs) to establish the overall success and the influencing factors. Patients and methods. Using a standardised recognised study protocol, meta-analysis of observational studies in epidemiology guidelines, a comprehensive review and analysis of the literature was performed. The primary outcome measure was the success of treatment. The search strategy and inclusion criteria which involved an assessment of quality yielded 39 articles for analysis, which included 1296 patients. Results. The proportion of success following DAIR in the management of an infected THA appeared to improve after 2004 with a pooled mean proportion of success of 72.2%. For all reported series, from 1977 onwards, there was improved success with early debridement (< 7 days; 75.7%) and exchange of modular components (77.5%). There was a statistically non-significant improvement if debridement was performed within four weeks of the initial procedure (73.0%). Conclusion. The reported success following DAIR has improved since 2004. The only determinants of outcome which we found were the timing of debridement after the onset of symptoms of infection and the exchange of modular components. Cite this article: Bone Joint J 2017;99-B:1488–66

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures. . We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD). . We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group. . The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived. . These findings have important implications for public health and preventative measures. . Cite this article: Bone Joint J 2015;97-B:240–5

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100 000 person-years. It was more common in women than in men (90 cases per 100 000 person-years in women and 83 per 100 000 person-years in men; p < 0.001). The highest incidence of 198 per 100 000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100 000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100 000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services. Cite this article: Bone Joint J 2014;96-B:350–3

Aims. To explore the of age of onset distribution for Perthes’ disease of the hip, with particular reference to gender, laterality and conformity to the lognormal distribution. Patients and Methods. A total of 1082 patients were identified from the Liverpool Perthes’ Disease Register between 1976 and 2010, of which 992 had the date of diagnosis recorded. In total, 682 patients came from the geographical area exclusively served by Alder Hey Hospital, of which 673 had a date of diagnosis. Age of onset curves were analysed, with respect to the predefined subgroups. Results. The age of onset demonstrated a positive skew with a median of 5.8 years (interquartile range 4.6 to 7.5). Disease onset was a mean five months earlier in girls (p = 0.01) and one year earlier in those who went on to develop bilateral disease (p < 0.001). There was no difference in the age of onset between geographical districts with differing incidence rates. The entire dataset (n = 992) conformed to a lognormal distribution graphically and with the chi-squared test of normality (p = 0.10), but not using the Shapiro-Wilk test (p = 0.01). The distribution for the predefined geographical subgroup (n = 673) conformed well to a lognormal distribution (chi-squared p = 0.16, Shapiro-Wilk p = 0.08). Given the observed lognormal distribution it was assumed that Perthes’ disease followed on incubation period consistent with a point-source disease exposure. The incubation period was further examined using Hirayama’s method, which suggested that the disease exposure may act in the prenatal period. Conclusion. The age of onset in Perthes’ disease conforms to a lognormal distribution, which allows comparisons with infectious disease epidemiology. Earlier onset in girls and those who develop bilateral disease may offer clues to understanding the aetiological determinants of the disease. The analysis suggests that an antenatal aetiological determinant may be responsible for disease. Take home message: Perthes’ disease age of onset conforms to a lognormal model, which is most typical of infectious diseases. The shape of the distribution suggests that an aetiological trigger in the pre-natal period may be an important determinant of disease. Cite this article: Bone Joint J 2016;98-B:710–14

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls. Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively. Cite this article: Bone Joint J 2014;96-B:366–72

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

Advances in the treatment of periprosthetic joint infections of the hip have once more pushed prosthesis preserving techniques into the limelight. At the same time, the common infecting organisms are evolving to become more resistant to conventional antimicrobial agents. Whilst the epidemiology of resistant staphylococci is changing, a number of recent reports have advocated the use of irrigation and debridement and one-stage revision for the treatment of periprosthetic joint infections due to resistant organisms. This review presents the available evidence for the treatment of periprosthetic joint infections of the hip, concentrating in particular on methicillin resistant staphylococci. . Cite this article: Bone Joint J 2014;96-B(11 Suppl A):60–5

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The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients.

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Temporary hemiepiphysiodesis (HED) is applied to children and adolescents to correct angular deformities (ADs) in long bones through guided growth. Traditional Blount staples or two-hole plates are mainly used for this indication. Despite precise surgical techniques and attentive postoperative follow-up, implant-associated complications are frequently described. To address these pitfalls, a flexible staple was developed to combine the advantages of the established implants. This study provides the first results of guided growth using the new implant and compares these with the established two-hole plates and Blount staples.

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Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences.

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The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries

Total hip replacement (THR) has been shown to be a cost-effective procedure. However, it is not risk-free. Certain conditions, such as diabetes mellitus, are thought to increase the risk of complications. In this study we have evaluated the prevalence of diabetes mellitus in patients undergoing THR and the associated risk of adverse operative outcomes. A meta-analysis and systematic review were conducted according to the guidelines of the meta-analysis of observational studies in epidemiology. Inclusion criteria were observational studies reporting the prevalence of diabetes in the study population, accompanied by reports of at least one of the following outcomes: venous thromboembolic events; acute coronary events; infections of the urinary tract, lower respiratory tract or surgical site; or requirement for revision arthroplasty. Altman and Bland’s methods were used to calculate differences in relative risks. The prevalence of diabetes mellitus was found to be 5.0% among patients undergoing THR, and was associated with an increased risk of established surgical site infection (odds ratio (OR) 2.04 (95% confidence interval (CI) 1.52 to 2.76)), urinary infection (OR 1.43 (95% CI 1.33 to 1.55)) and lower respiratory tract infections (OR 1.95 (95% CI 1.61 to 2.26)). Diabetes mellitus is a relatively common comorbidity encountered in THR. Diabetic patients have a higher rate of developing both surgical site and non-surgical site infections following THR. Cite this article: Bone Joint J 2013;95-B:1474–9

We prospectively analysed the epidemiology of acetabular fractures over a period of 16 years in order to identify changes in their incidence or other demographic features. Our study cohort comprised a consecutive series of 351 patients with acetabular fractures admitted to a single institution between January 1988 and December 2003. There was no significant change in the overall incidence of acetabular fractures, which remained at 3 patients/100 000/year. There was, however, a significant reduction in the number of men sustaining an acetabular fracture over the period (p < 0.02). The number of fractures resulting from falls from a height < 10 feet showed a significant increase (p < 0.002), but there was no change in those caused by motor-vehicle accidents. There was a significant reduction in the median Injury Severity score over the period which was associated with a significant decrease in mortality (p < 0.04) and a reduction in the length of hospital stay. The incidence of osteoarthritis noted during follow-up of operatively-treated fractures declined from 31% to 14%, reflecting improved results with increasing subspecialisation. Our findings suggest that there will be a continuing need for some orthopaedic surgeons to specialise in the management of these fractures. In addition, the reductions in the Injury Severity score and mortality may be associated with improved road and vehicle safety